Prefixing “Dr”: Taking the Shine Away

Reproduced from: http://www.indialegallive.com/viewpoint/prefixing-dr-taking-the-shine-away-66572, published June 6, 2019

With the pharmacy council allowing its degree holders to use the “Dr” prefix, practitioners of modern medicine are irked and patients are left confused as to whom to go to in an emergency   

By Dr KK Aggarwal

As per Medical Council of India (MCI) ethics regulation 2.1, every doctor has an obligation towards the sick: “Though a physician is not bound to treat each and every person asking his services, he should not only be ever ready to respond to the calls of the sick and the injured, but should be mindful of the high character of his mission… A physician advising a patient to seek service of another physician is acceptable, however, in case of emergency a physician must treat the patient. No physician shall arbitrarily refuse treatment to a patient…”

Regulation 2.4 says: “The patient must not be neglected: A physician is free to choose whom he will serve. He should, however, respond to any request for his assistance in an emergency….”

In an emergency situation, the only answer is a modern medicine doctor or one registered with the Medical Council of India.

But it is regulation 1.1.3 that is especially important and defines who is a physician: “No person other than a doctor having qualification recognised by Medical Council of India and registered with Medical Council of India/State Medical Council(s) is allowed to practice Modern system of Medicine or Surgery. A person obtaining qualification in any other system of Medicine is not allowed to practice Modern system of Medicine in any form.” So, in an emergency, the public must find a doctor with an MBBS degree and the accepted way of doing it is to search for a person who has prefixed Dr before his name.

MCI ethics regulation 1.4.2 also says: “Physicians shall display as suffix to their names only recognised medical degrees or such certificates/diplomas and memberships/honours which confer professional knowledge or recognises any exemplary qualification/achievements.” In the case of MBBS doctors, it will be modern medicine.

Article 18 of the Constitution talks about abolition of titles: “No title, not being a military or academic distinction, shall be conferred by the State. No states can officially issue titles.” When I got the Padma Shri by the president in 2010, I was cited a Supreme Court ruling as part of the briefing: I cannot use Padma Shri Dr KK Aggarwal under Article 18. But I can use Padma Shri awardee Dr KK Aggarwal or recipient of Padma Shri Dr KK Aggarwal.

The prefix Dr used by modern medicine doctors is not given by the Medical Council of India, a medical college or a state university, but by society to differentiate us from others and identify us as modern medicine doctors. However, today, even a person who has completed doctoral research and is awarded a PhD, prefixes Dr to his name. Practitioners of AYUSH systems of medicine also prefix their names with Dr even though they have their own appropriate terms such as Vaidya (Ayurveda), Hakim (Unani), Naturopath (Naturopathy), Yogacharya (Yoga) and Homoeopath (Homeopathy). One must remember that in an emergency, these systems of medicine are not effective. That’s not all. Universities also felicitate eminent individuals for their contribution in many fields such as literature, science, sports, music, cinema, social service, etc, with doctorate degrees. These individuals also prefix Dr to their names.

Now there is talk of the Pharmacy Council of India (PCI) authorising candidates receiving the Doctor of Pharmacy degree (Pharm D) from recognised universities to use the “Dr” prefix. This title reflects entitlement and identity and the Indian Medical Association (IMA) is against it being used by those trained in other streams of medicine as it confuses people during medical emergencies. In a letter issued to the director of Board of Examination and Evaluation of Sant Gadge Baba Amravati University, the registrar-cum-secretary of the PCI, Archana Mudgal, has informed that the University should use the “Dr” prefix before the names of candidates while awarding them degrees. But as universities in Maharashtra were not issuing degrees with “Dr” prefix, members of the Doctor of Pharmacy Association of Maharashtra approached the PCI for clarification. The PCI then issued a circular stating that Pharm D candidates can use Dr before their names. Legally, this is only an executive order and not a legally sanctioned clause.

Physiotherapists have also been asking for Dr as a prefix. Tomorrow, even nurses will start writing Dr as a prefix. Of course, quacks are also prefixing Dr before their names. And surprisingly, even health products are using Dr liberally such as Dr Morpen, Dr Fixit, etc.

The use of Dr as a prefix is widespread, be it dentists, veterinary doctors, acupressure and acupuncture specialists or occupational experts. The easiest solution to distinguish these branches of medicine would be to have specific degrees such as XYZ, Doctor of Pharmacy.

When I was the National President of the IMA, this matter was discussed on many occasions. We were getting many complaints from the public of being misguided and exploited by untrained doctors during emergencies.

Different variations of Dr were being used—DR, DR., Doc, Doc., Doctor, Dr (Modern Medicine), Dr (Homeopathy), Dr (Ayurveda), Dr (Naturopathy), Dr (Dental), Dr (Veterinary), Dr (Yoga), etc. I personally started carrying a stethoscope around my neck as a symbol of modern medicine and being available in any emergency.

While one can stop pharmacists or physiotherapists from using Dr before their names, one will never be able to stop AYUSH doctors from doing the same. So the IMA copyrighted an emblem for modern medicine which is to be used by all its doctors to differentiate themselves from those in other fields.

The government must come out with a regulation so that ordinary people can differentiate between doctors of different systems of medicine. The confusion can cause fatal errors and delay in treatments. Will the government listen or should we again look to the judiciary to intervene and take a decision?

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Assistant Ambulance Officers: Save a Life First

Reproduced from: http://www.indialegallive.com/viewpoint/assistant-ambulance-officers-save-a-life-first-65657, published May 19, 2019

The debate over Assistant Ambulance Officers is needless, as in any medical emergency, what is vital is to save the life of the patient, even by a bystander

By Dr KK Aggarwal

A scheme started by the Delhi government in February seems to have run into trouble and has reached the Delhi High Court. A PIL has said that Assistant Ambulance Officers (AAOs) who are assigned the job of driving two-wheeler First Responder Vehicles should also be trained paramedics. However, the Delhi government has said that they will not transport patients and will only give basic medical assistance until an ambulance arrives.

AAOs have been trained in basic life-support techniques, have commercial driving licences and a work experience of more than 20 years. However, in this scheme, there is not much efficacy due to the limited knowledge and training of AAOs. They are not even authorised (or qualified) to administer an injection.

To understand their job, we need to first understand the laws. The government has powers to allow healthcare workers to give treatment under Clause 23 of Schedule K of the Drugs and Cosmetics Act.

As per the Clause, drugs supplied by certain categories of workers are exempted from the provisions of Chapter IV of the Act and the Rules which require them to be covered by a sale licence, provided the drugs are supplied under the Health or Family Welfare Programme of the central or state government. The workers are:

·         Multipurpose workers attached to primary health centres/sub-centres.

·         Community health volunteers under the Rural Health Scheme.

·         Nurses, auxiliary nurses, midwives and lady health visitors attached to urban family welfare centres/primary health centres/sub-centres.

·         Anganwadi workers.

Similarly, malaria workers are given anti-malaria drugs and do malaria testing, ASHA workers are allowed to give Gentamicin injections to newborns and methergine for postpartum haemorrhage, a leading cause of maternal mortality, before the patient is transferred to a hospital.

There is also a provision in the Medical Council of India ethics rules where a technician can be trained by a doctor. It does not talk about institutional training. It says: “A registered medical practitioner shall not issue certificates of efficiency in modern medicine to an unqualified or non-medical person.” This does not restrict the proper training and instruction of bona fide students, midwives, dispensers, surgical attendants, skilled mechanical and technical assistants and therapy assistants under the personal supervision of physicians.

Similarly, in cases of a cardiac arrest, even bystanders are allowed to provide cardiopulmonary resuscitation (CPR). There are three phases of cardiac resuscitation lasting a total of 10 minutes. No doctor can reach in 10 minutes in an emergency and that is why a first responder is important.

The first phase of resuscitation is the electrical phase, lasting four to five minutes after sudden cardiac arrest (SCA). Immediate direct current cardioversion is needed to convert an abnormal heart rhythm to a normal heart rhythm. Performing chest compressions while the defibrillator is readied also improves survival. Then, there is the hemodynamic phase or circulatory phase which is from four to 10 minutes after SCA. Chest compressions should be started immediately and continued until just before defibrillation is performed. Then there is the metabolic phase defined as greater than 10 minutes of pulselessness. This is primarily based upon post-resuscitative measures. In these phases, the administration of CPR by a lay person is an important factor in determining patient outcome if the cardiac arrest takes place outside a hospital. Survival after cardiac arrest is greater among those who have bystander CPR as compared to those who initially receive delayed CPR from a trained technician. In addition to improved survival, early restoration in circulation is also seen.

There is also the golden hour in medical practice when immediate care is required. Delay in treatment even by a few minutes can take away a life. In emergency medicine, the golden hour refers to the first hour following a traumatic injury during which time there is the greatest likelihood that prompt medical treatment will prevent death.

If bleeding can be stopped and a person infused with enough fluids within the first hour, most trauma deaths can be avoided. There is also the platinum 10 minutes which refers to the first 10 minutes after trauma when first-aid can be started.

The importance of time in medicine can be gauged from the following:

·         Door to ECG Time: This is an important terminology in the treatment of heart attack. One should get an ECG within 10 minutes of chest pain. A prolonged door-to-ECG time is associated with an increased risk in a heart attack.

·         Door-to-doctor time in paralysis: In an emergency department, the time from the arrival of the patient to initial physician evaluation should be less than 10 minutes in strokes, otherwise the mortality will be high.

·         Door to antibiotic time in community acquired pneumonia is the time to start antibiotics. Guidelines suggest that all patients hospitalised with community acquired pneumonia should receive antibiotics within four hours of admission in a hospital.

·         Door to antibiotic time in meningitis of more than six hours is linked to high mortality.

·         Door to needle time in an acute heart attack is the time before which a clot-dissolving drug should be given.

·         Door to balloon time is less than 90 minutes for angioplasty and stenting in acute heart attack.

Even the Indian Penal Code (Section 92) recognises the importance of an act done in good faith with consent. It says: “Nothing is an offence by reason of any harm which it may cause to a person for whose benefit it is done in good faith, even without that person’s consent, if the circumstances are such that it is impossible for that person to signify consent, or if that person is incapable of giving consent, and has no guardian or other person in lawful charge of him from whom it is possible to obtain consent in time for the thing to be done with benefit.”

In that sense, motorcycle first responders are important. They are not doctors and will give life-saving intervention only when required. Under Section 88, the same Act is not an offence if done with consent. Calling an ambulance is an implied consent.

In this whole issue, there is the question of paramedics. Are there enough paramedic courses, colleges and councils? From the Red Cross, one can do a short course on first-aid and qualify to be a paramedic. But is that enough?

The answer lies in training and not the degree as far as first-aid is concerned. It is important to manage the golden hour and hand over the patient to qualified doctors with the arrival of a proper ambulance.

Time is of essence in medical care and if basic first-aid is being given, why quibble about whether the person has a paramedical degree or not?

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA