Specialists have become commercial money making machines-Rasheed Jooma


Neurology Conference proceedings-I

Specialists have become commercial
money making machines - Rasheed Jooma

Doctors should be thinking about
cost effective care all the time

KARACHI: Specialists have become commercial money making machines. Doctors should be thinking of cost effective healthcare all the time. Healthcare professionals should become true advocate for the patient and volunteer some of their time for any cause beyond their self concern. By doing so they will be better able to project value of their professional specialty organization. This was stated by Prof. Rasheed Jooma, a noted neurosurgeon who also served as Director General of Health, Government of Pakistan. He was speaking at the 21st Neurology conference organized by Pakistan Society of Neurology at Karachi from March28-30, 2014. The topic of his presentation was Advocacy for Neurology Care in Pakistan.

Prof. Wasay (Left) and Prof. Shaukat Ali (Right) presenting a memento
to Prof. Rashid Jooma former DG Health seen in the center who was one
of the invited guest speakers at the recently concluded Neurology 
Conference held at Karachi from March 28 to 30, 2014.

Medicine, Prof. Rasheed Jooma opined is a vocation and profession, we must keep commercial aspects out of it and if we do so, we have a greater chances of success. His advice to the Pakistan Society of Neurology was to devote resources to a Foundation which works as an advocacy group for neurology. Professional groups do work with media advocacy groups. It should be an independent arm of the society which should be working in the area of your professional interest. We need to promote social medicine as it is our duty to the society, he remarked.
At present neurology conditions are poorly reported, these diseases are under diagnosed and were also complex to manage. It provides space for alternate practices like faith healers, non-qualified doctors as well as traditional medical practitioners. All these people, Prof. Jooma remarked were doing a good job and they should be brought into the main spectrum. He recalled that once he was staying in a village in the interior of Sindh and he saw a large number of people gathered in front of a house at night. Enquiries revealed that someone who worked as compounder in a hospital lives here and he is available to the local people all the time. Hence all these people had gathered to seek treatment. These people live there in the society, are available to the people all the time and sometimes they are the only ones available to whom the public looks for care. As such they do provide some service. Instead of condemning them, we should bring them into the mainstream as their services are needed. We have a paucity of qualified neurologists and people have a limited access to them. Only a fraction of the population suffering from neurological disorders gets evaluated, treated by modern methods. If we look at the geographic distribution of neurologists, it will reveal that almost all of them are practicing in the major cities and centers. We need to expand the access of people to specialists and enhance awareness about the neurology services. We need to educate the bureaucrats and make sure that qualified neurologists are posted at all the DHQ Hospitals in the country.
Replying to a question Prof.Rasheed Jooma said that he has always believed that professional specialty organizations is a very important resource which is not being utilized properly. He agreed that these professional specialty organizations should monitor their members, hold them accountable and ensure that they practice ethical medicine. If the specialists devote their time for some social work, promote social, preventive medicine, make healthcare cost effective, it will give credit to their association as well as the medical profession. We do need more neurologists keeping in view the disease burden, he remarked.

Postgraduate Training in Neurology

Earlier speaking about the postgraduate training in neurology in Pakistan, Dr.Sarwar J.Siddiqui Dean of Faculty of Neurology at CPSP said that neurology service started in Pakistan forty seven years ago. At that time all the neurologists were foreign qualified. King Edward Medical College at Lahore and JPMC in Karachi had Dept. of Neurology. In 1990, many neurologists came back from abroad and at present there are 142 qualified neurologists in Pakistan, 85% of them were trained in Pakistan. Forty Five doctors with FCPS in neurology are working in Middle East. United States has 17,220 neurologists, UK has six hundred sixty two 662, India has twelve hundred (1200) neurologists, Bangladesh has sixty neurologists, Indonesia 720, Malaysia fifty (50) and Philippines has two hundred seventy (270) neurologists. In Pakistan we have FCPS in Neurology by CPSP, MD in Neurology awarded by various medical universities and JPMC also had Diploma in Clinical Neurology but it is no more popular.
Presently there are seventeen centers recognized for training in neurology, twenty one accredited supervisors in this specialty and one hundred four trainees are registered who are getting training. This includes fifty trainees in Punjab, forty four in Sindh and Ten in KPK. Currently two training centers have no supervisors. There is vast different in quality of training in various centers. Patient volume is also quite different in public and private institutions. MRI is available at some centers but stroke unit is not available at all the centers. Rehabilitation services are deficient. He also referred to the lack of structured training programme. Acute neurology cases are admitted under internal medicine. Number of consultants and patient work load is different in various places. There is lose control as regards hiring and firing. There is lot political interference in postings. Added to this is the lack of technology and support staff. Most often Head of the Department is never consulted for induction of trainees. We have improved the curriculum as well as the exam process. The number of supervisors and accredited training centers has also increased. There is a need to re-inspect the existing accredited training centers to bring parity among them. Faculty number is more or less the same. We need to look into the establishment of stroke units and acute admissions. There is a need to get feedback from the supervisors as well as the trainees.
Continuing Dr. Sarwar Siddiqui stated that we wish to have designated structured training programme, say in induction process of trainees and these trainees also need to be rotated in different centers during their training. Those training centers which do not fulfill the laid down criteria should be immediately derecognized. The whole faculty of neurology, he opined, should be working as an advocacy group for neurology, make sure that stroke units are established at all the major hospitals besides making available MRI facilities for screening. He also disclosed that CPSP is working on starting Fellowship in sub-specialties like Neurovascular stroke medicine and neurophysiology in the next two to three years. He also disclosed that there was a move by some which he neither liked nor supported that people should first do FCPS in neurology and then go for sub-specialization in neurology. It is not feasible and practical. On the contrary, during the rotation of the trainees, training in internal medicine needs to be strengthened, he remarked.

Psychiatry interface with Neurology

Prof. Iqbal Afridi from JPMC spoke about psychiatry’s interface with neurology. He pointed out that the fault with the modern physician was that they have separated body from soul though it is not possible. Referring to one of the study they had conducted at JPMC, he said, it showed that 36.1% patients had lot of co-morbidity. There is lot of overlapping in neurology and psychiatry and there is lot of gray areas as well which form neuropsychiatric disorders. In the past facility as JPMC was known as Neuropsychiatry. It is important that we use our brain otherwise one can lose it as dystrophy can occur in the brain. In future anti-depressants may work as anti dementia drugs. There is interchange in dementia, Alzheimer’s disease, mental retardation, epilepsy. Almost 23% of patients can have many other diseases which should be treated.
Speaking about depression and stroke, Prof. Iqbal Afridi said that studies have showed that if stroke is on right side, it is mania and if stroke is on left side, patients will suffer from depression. Almost 50% of Parkinson’s disease patients can have anxiety. Multiple sclerosis and psychosis can also occur in these patients. Many patients suffering from psychiatric diseases also have some neurological disorders hence availability of neuropsychiatry service will improve the patients quality of life as well as of the care givers. It is important that psychiatrists have some basic knowledge of neurology and similarly neurologists must have some basic knowledge of psychiatry and we must see the patient holistically, he added.
Prof. Junaid Ashraf speaking on Neurosurgery care and interface with neurology said that neurology as a discipline and specialty is much older than neurosurgery. In the past it was the neurologists who used to make diagnosis for the neurosurgeons to operate and neurosurgery was an extended hand of neurologists. In case of tumours, localization was done by neurologist and then the neurosurgeons used to operate on these patients. It was Harvey Cushing’s who introduced many new things including the blood pressure measurement. There is complete overlap between neurologists and neurosurgeons and they both work together. When angiography became available, we had CT scan and MRI, the diagnosis became a bit easier and it also diversified neurology and both these disciplines got separated. Neurology now has many sub-specialties like epilepsy, spine, and oncology. When cerebrovascular brain tumours are diagnosed, they are operated upon by neurosurgeons. They also perform surgery for stroke, surgery for aneurysm, AVMs, surgery of degenerative spinal disorders and they interact with neurologists.
In case of surgery for epilepsy, there is a strong collaboration between the neurosurgeons and neurologists. Similarly stroke, movement disorders, deep brain stimulation are areas where collaboration between neurologists and neurosurgeons are going to be everlasting. Neurosurgeons will be needed for neuro rehabilitation. Their services will be required to implant chips. With the latest developments, radiologists are taking away many functions through radio surgery and cyber knife procedures. In the days to come we will need much more collaboration between the engineers, physiologists, neurologists and neurosurgeons, Prof. Junaid Ashraf remarked.