Perspectives of Rural Surgeons
Scope and Limitations of Rural Surgery
Ravindranath R. Tongaonkar
Dr. Tongaonkar Hospital, Dondaicha, Dist. Dhule (Mah)
Paper received : June 2002
Code Number: is03004
What a Rural Surgeon can do in his small place totally depends on his personal ability and facilities available to him. As regards scope in Rural surgery he can do anything and sky is the limit. But there are many limitations, which can be broadly divided into three, namely technical problems, professional skill and legal problems.
The technical problems mainly include non-availability of adequate equipment, no facilities for investigations and unqualified paramedic staff.
The single most limiting factor is the professional skill of the surgeon, which depends on the training he has received during his postgraduate studies and his desire and ability to learn newer techniques, after he settles in his practice. The recently launched 'Certificate in Rural Surgery' (CRS) programme by Indira Gandhi National Open University, New Delhi in collaboration with Association of Rural Surgeons in India will definitely help the Rural surgeon to improve his professional skill.
Legal problems have arisen because of many new laws recently introduced in India, which are affecting the Rural Surgeons. If the laws are followed verbatim rural surgeons will have to stop working. There is a need to unite together and fight against these Laws, which are limiting the scope of rural surgery.
Keywords: Rural Surgery: Scope And Limitations, Certificate In Rural Surgery, Laws Affecting.
Rural Surgery or Surgery in Rural areas is no way different or inferior to surgery carried out any where in the world except that it is done by a single handed Rural Surgeon under resource constraints1. This is also reiterated by the World Medical Assembly in 1964 at Helsinki and again in 1983 at Venice in its recommendations concerning medical care in rural areas where it is emphasised that 'Although there may be economic and other factors affecting the quantity of medical services available in rural areas there should be no disparity in the quality of medical services2. The same holds good for rural surgery. If so, what is the Scope in Rural Surgery and what are the limitations?
SCOPE IN RURAL SURGERY
How much to do and how far to do, totally depends on the surgeon himself, his capability, his training, ambition and desire to learn and do as many surgical procedures as he can, in his small set up. No body can prevent him from doing anything he wants to do. Sky is the limit.
Besides routine surgical procedures one can certainly do all types of major surgeries like cholecystectomies, nephrectomies, hemicolectomies, intestinal resections, thyroidectomies, radical mastectomies and repair of big Incisional hernias. One can do all plastic, paediatric, urologic and orthopaedic surgery and carry out all gynaecological and obstetrical procedures including caesarean sections and hysterectomies3. More than 80% of rural surgeons in India are already doing urological, obstetrical and gynaecological work4. If the surgeon wants, he can avail of all sophisticated techniques like ultrasonography, Upper G. I. endoscopies, urological endoscopies including doing TUR prostates and laparoscopic techniques using video-endoscopy.
The lack sophisticated equipment and non-availability of qualified paramedics does not deter him. Dr. Sitanath De of Jhargram, a small town in West Bengal does definitive procedure like vagotomy and gastrojejunostomy for patients with perforated duodenal ulcers on a simple wooden table with ordinary 200 watt bulb, under open Ether anaesthesia administrated by a general practitioner5. He also does other major surgeries like gastrectomies, common bile duct exploration and pancreatic surgery, under the same settings.
The extreme climatic conditions of the nature do not affect his working. Dr. K.C. Sharma of Udhampur (J and K) performs surgeries under sub-zero temperatures at Ladhakh where everything including saline freezes6. Dr. Prabhakar Mhaskar from Amalner does hundreds of surgeries going from village to village in his 'Hospital on the Wheels'.Dr. Sadanand Mishra, in charge of Primary Health Centre of Bankoi in Orissa, has to work without gloves and gowns and not even a nurse to assist. Dr. Lalita and Regi of Sittilingi, a tribal village in Tamilnadu are not only doing surgery in Tribal areas but also training health workers in small villages. Dr. Oluyombo Awojobi of Eruwa, Nigeria has no access to newer gadgets but does excellent work in his small rural hospital. He uses a makeshift centrifuge working on a bicycle wheel to examine urine. They collect rainwater from roofs and store the water to be used during summers. We had opportunity to witness, Sadanand's, Lalita's and Oluyombo's works during our 9th Annual Conference on Rural surgery at Jagannath Puri in Nov. 2001.
At the other extreme, Dr. Sivasubramanium from Settiarpatti a small town in Tamilnadu near Kanyakumari does everything including myocutaneous flaps, oesophageal resections for malignancies, nailing fracture neck femurs, laparoscopic cholecystectomies and laparoscopic assisted vaginal hysterectomies doing all these procedures single handedly giving epidural Anaesthesia himself.
Last year in 2001 his paper on 'Gasless Laparoscopic Abdomino-Perineal (AP) resection under epidural anaesthesia,' a procedure devised by himself, was selected for poster presentation in the World Congress on Laparoscopy at Singapore,
These are only the glimpses of the commendable work rural surgeons are doing across the country and across the world. This exemplifies the truth that if a rural surgeon desires he can do anything, anywhere, under any circumstances and any settings. Dr. T. E. Udwadia also agrees to this fact7.
One of the finest surgical clinic in the world the Mayo clinic of America was also started in a small village.
LIMITATIONS IN RURAL SURGERY
If this is so then what prevents most of the rural surgeons from not doing anything major than piles, fistulas, hernias and hydrocele and limiting at the most to appendectomies and referring the patient to a bigger centre as soon as anything else is found? Recently a surgeon near by authors town had taken a patient for appendectomy but after opening the abdomen he found a gangrenous loop of intestine, instead of doing resection and anastomosis he closed the wound and sent the patient to the author. Why he did so? What prevented him going ahead and doing the basic procedure of simple resection anastomosis of intestine which every general surgeon ought to know? What are the limiting factors in rural surgery?
Limitations in Rural surgery can be broadly divided into three, viz.
1) Technical problems.
The Technical problems can be due to non-availability of good building, good and adequate equipment, facilities for investigations, non-availability of qualified paramedic staff, including qualified anaesthetist, and many others. Lack of funds to an individual private rural surgeon is one of the most important limiting factor.
But if one wishes, all these can be easily overcome. Building can be modified, at least internally using false roofs and false walls. Minimum required investigations can be done by the surgeon himself setting his own small laboratory. He can have his small 50 mA X-ray unit on which, with practice and improving on techniques, one can take excellent pictures, even do barium meal studies and intravenous urographies. Most of the operations can be done on simple operation table, with ordinary light and minimum standard equipment. Similarly any major surgery can be done using Oxford type of bellows and air ether mixture 3, 8 . Staff problem can be solved by keeping a large staff trained by the surgeon himself. To have the medico spouse is a great boon to rural surgeon and he or she should insist to have a medical spouse. Even though unqualified, well trained staff can do excellent work if properly taught. If availability of funds is the problem one can always take loans from banks or relatives or equipment can be added slowly3 as and when funds become available as done by the author over last 34 years. Starting with 4 beds in a hundred years old building and minimum equipment, the author kept on adding new gadgets and equipment every year or two. Now the author has 25 bedded well equipped hospital with 4 new buildings, 2 air-conditioned operation theatres, Boyles apparatus, ventilators, pulse-oximeter, an ultrasonography machine, and facilities for upper G. I., urologic and video-endoscopic procedures.
The author personally thinks that all these technical factors should not be the limiting factors to do most of the surgery in Rural areas.
The single most limiting factor probably is the professional knowledge, skill and expertise of the operating surgeon, both before and after opening his hospital.
If the surgeon is not properly trained and does not have enough experience of doing various procedures on his own and does not take special efforts to learn new techniques, he is afraid to undertake any major or complicated surgery alone in a remote place and becomes only a referring doctor. Recently, the author met a newly qualified surgeon who said that he had hardly done 4 hernias on his own during his residency, leave aside doing any major surgeries. He was scared to start his private practice and even to do minor surgery.
On the contrary another young surgeon just passed from another medical college told that he has done over eighty open prostaetectomies, and many other major surgeries under the supervision of his teacher. This surgeon will never hesitate in doing any major surgery anywhere, but such opportunities are far and few. Most of the surgeons have hardly any experience when they pass out, and it is absolutely necessary to keep on learning and adding knowledge by reading books, attending workshops and conferences and personal visits to learned people3.
The author did his first vagotomy, thyroidectomy and pyelolitholoy in his place. His knowledge of caesarean section when he passed his MS, was limited to whatever he had seen as an undergraduate sitting in the operation theatre gallery. He had to learn it himself by reading books. He did his first cholecystectomy after 20 years of his practice learning it by going to Mumbai and observing surgery done by senior teachers. At the same time the author learnt upper G. I. endoscopy. Similarly at the age of fifty he learnt urologic endoscopy and transurethral resection of prostate practising first on a potato model.
At the age of 55 when people think of retiring the author stayed for one month in undergraduate student's hostel of K.E.M Hospital, Mumbai and learnt ultrasonography.
Unless one takes such special efforts one can never progress in life.
The recently launched Certificate in Rural Surgery Programme (CRS) by Indira Gandhi National Open University, New Delhi, in collaboration with Association of Rural Surgeons of India, is a well planned distant education programme, which can update the knowledge of the rural surgeon and rural gynaecologist giving compressive training in surgery and allied branches. This will certainly help rural surgeon to widen scope in Rural Surgery. Legally nobody can prevent him doing anything. By law even an MBBS person can do any surgery because he posses Bachelor of Surgery qualification.
Till few years before there were hardly any Laws governing the medical practice either in urban or rural areas and even if they existed, they were not strictly implemented by the concerned authorities. The medical practitioner was only expected to follow the code of conduct and rules given by the respective medical councils while giving registration to practice Medicine.
A sincere, faithful and law abiding medical practitioner could do anything ethically and legally to serve his patients, but in recent years there is spurt of numerous new Acts and Rules, which if followed verbatim would make medical (and surgical) practice in the frame work of Law almost impossible, specially in rural areas. If a rural surgeon strictly follows all the Laws, his practice will be limited only to clinical examination of the patient and referring him to higher centres for surgery. He will not be able to do any investigations leave aside doing any surgery as simple as incising an abscess!
Let us see how-
Health being a 'State' Subject (Entry 6 of List II of 7th schedule to the Constitution of India) it is the State legislature that makes laws on the subject so legislation on health may not be uniform through out India9 and will vary from State to State.
Following are glimpses of some of the requirements of some Acts and their effect on Rural surgical practice (given in bracket).
Atomic Energy Act. 1962:, Radiation protection Rules 1971, AERB Safety code No. AERB/SC/Med.2 (Rev.1) 2001- Regarding Operation of medical x-ray machines by hospitals, Clinics.
Employ qualified staff (Non-compliance will result in closure of defaulting X-ray institution.)
[In Rural areas qualified Radiologist and x-ray technicians are not available therefore he cannot run x-ray machine]
Maharashtra Pathology Laboratory control Rules 1997: (III) Requirements of Staff
For category 'C' laboratories (Smallest Laboratory)-
Incharge at the Laboratory shall possess a MBBS degree with having at least 5 years experience of work in any pathology laboratory covered under category A or B laboratories.
[A rural surgeon who used to have his own, small laboratory can never have experience of 5 years working in any laboratory neither would there be any other MBBS person in his town having this experience or having postgraduate diploma or degree in pathology. So under the New Law, he will not get the Licence to run the laboratory and will not able to do even haemoglobin or urine examination of his patient!]
The Karnataka Private Medical Establishments (Regulation) Bill. 1998 [L. C. Bill No. 15 of 1998]:
Section 7.II) That the Private Medical Establishment is adequately staffed with qualified doctors, nurses, technical and other paramedical personnel.
[From where a Rural surgeon can get qualified nurses and other paramedical personnel? Either he has to do everything personally, without appointing any nurse or paramedic or close his nursing home!]
Bombay Nursing Home Act 1949 and (Proposed Maharashtra Clinical Establishment Act 2001):
Fulfil and conform to requirement (Standards) framed from time to time. These standards may apply to structure, staff, building, space requirement, equipment or other facilities.
Registration under this Act is compulsory, penalty for non Registration-Imprisonment for 2 years and/or fine Rs. 10,000/-
[If any of the requirement, is not fulfilled-registration cancelled, then either stop working or get imprisonment.]
Drug and Cosmetics Act 1940 (23 of 1940) and Drugs and Cosmetic Rules 1945,-Drug and Cosmeties (2nd Amendment) Rules 1999 Part X- B:
(Regarding Blood Banks)-Only the licensed blood banks can collect the blood. The requirement for blood bank- specially qualified staff, minimum 100 sq meters (1000 sq-feet) area, with 4 air-conditioned rooms and costly equipment.
[Prior to these rules it was perfectly legal for even an MBBS doctor to collect blood from a donor, do all the necessary tests and transfuse the fresh blood to his patient in his own hospital without obtaining a licence to run a blood bank.
The procedure was termed Unbanked Direct Blood Transfusion (UDBT).
Because of new rules he cannot collect blood neither can set up a blood bank. In such situations in dire emergencies either the rural surgeon has to let his bleeding patient die or break the law and save the patient by giving urgent blood transfusion using UDBT.]
But there is a good news, because of constant efforts of Association of Rural Surgeons of India and other well-wishers of rural community, the Government has realised the need of blood in rural areas and now has come out with the idea of legalising Blood Storage Centres in rural areas, where blood collected and tested in the Regional Blood Banks can be stored and used by rural doctors.
Prenatal Diagnostic Techniques (PNDT) Act 1996:
The Rural Surgeon or Gynaecologist having an ultrasonography machine will have to register under this act and comply to the requirements [or close down the unit].
Bio-medical waste (Management and Handling) Rules, 1966, 1998 and Amendment Rules 2000: under these rules every hospital has to apply for obtaining authorisation and must obey the rules suggested by the Law. The Law states that any establishment generating biomedical waste should have either an incinerator or microwave processor to burn the waste.
[The authorities do not clarify about the type of incinerator or microwave, its availability etc. Internet browsing on the subject gives interesting information.
Global Response Action Update Oct 1997 advises the World Bank to stop construction of medical waste incinerators in India as they belch out toxins and toxic ash.
News in 'The Times of India New Delhi-23rd May 2001'-"Hospital waste disposal system developed for 28 major hospitals of the Armed Forces at total outlay of Rs.103 Crores." That means Rs. 4 Crores for each hospital.
Recent personal communication to author-a smallest incinerator (with a chimney of 100 feet) available in Maharashtra will cost around Rs. 2,00,000/-, running and maintenance cost extra.
Can every rural surgeon afford to set up such an Incinerator?
Does the Government expect each small hospital to spend, may not be Crores of Rupees but Lacs of rupees to develop waste disposal systems of their own? Non-compliance of which will, result in closing down of the establishment.]
The Consumer Protection Act: the enactment of consumer protection act has also put great limitations on the practice of the rural surgeon.
The recent spurt of many cases against the rural surgeons in the Consumer Courts has made him cautious in treating his patients. Nobody is ready to accept bad risk patients. Now the General Surgeons are thinking twice before handling cases from other allied branches of surgery like orthopaedics or gynaecology.
The author who used to treat all fractures has stopped admitting fractures of both bones of forearms, fracture tibia and fracture femurs. Because now even minor acceptable deformities or occasional non-union or delayed union may result in filing suit against him.
Criminal Laws: IPC Act 1861 section 304 Part II and 304A "Punishment for Culpable Homicide not amounting to Murder".
[Hot discussions are going on whether to apply 304 or 304A of IPC in case of death in the hospital due to negligence. Who would like to go to jail if a bad risk patient dies in his hospital. Better not to accept the patient. But it is to be remembered that if admission and treatment is denied to such a moribund patient and if that patient dies, this will also invite section 304A for not rendering services and being responsible for death. Either way the doctor is punished!]
This simply means that if the rural surgeon has to follow all these Laws verbatim he will have to close down his hospital and either migrate to big cities or be merely a referring doctor or continue his practices breaking all the laws and be ready to face imprisonment!
In long run because of all these laws there will be many limitations on the scope of Rural Surgery, unless the rural surgeons unite and voice against these laws and get them amended.
Solution to the Legal Problems: To discuss these legal and ethical matters, the Association of Rural Surgeons of India and Rural Medicare Society, Delhi, arranged a round table conference with some of the Supreme Court advocates in New Delhi, in 1999.
One of the participant, Shri Dipankar Gupta, senior advocate Supreme Court and former solicitor General of India, New Delhi, said "One cannot say in a sweeping language that laws are bad." "It is true that the problems faced by the rural surgeons are not the same as their urban counterparts and standards to be applied cannot be the same. It is a case of unequal being treated as equals."
He further says that, "Lot of inputs go into making a legislation and many view points are reflected. It is perhaps possible that your (rural surgeons') problems and view points have not been appreciated while making the law because there was no knowledge of your problems to the people making the law" and "It is necessary that your view points are also reflected in the law, for this, dedicated and responsible people facing the impediments created by the new laws should voice their problems through such forum."(Association of Rural Surgeons of India)9.
Another advocate from Supreme court Mr. Manoj Chatterjee also endorses Deepankar Gupta's views and advises to do a lot of research and collect statistics from people working and rendering such services in the rural areas, and highlight the problems in news papers and media then only approach the court."9
Mr. D. P. Mukherjee, one more Supreme Court advocate also agrees to this and says, "The issue must get injected in the minds of people and the legislators." 9
Let us all unite to build up our own case and let the legislators and people know our problems, so that the existing laws will be amended and new Laws will be made in such a way that they will not pose limitations to working of a Rural surgeon who can then utilise all his wisdom and wit, to take Rural Surgery to sweeping heights for which Sky is the only limit!
Copyright 2003 - Indian Journal of Surgery. Also available online at http://www.indianjsurg.com