Comment

A misguided policy that cuts deep into patient safety

The basic requirement of medical practice is the safety of the patient. Surgery is a branch of medicine in which poor training can have dramatic and disastrous results. This is the strongest argument against the ill-advised move of the government of India to allow graduates in Ayurveda to practise surgery.

Apprenticeship is key

Surgery in the present era is an interdisciplinary endeavour. A well-trained anaesthesiologist keeps the patient free of pain. Other specialist doctors address any other illnesses that the patient has before surgery can be safely performed. The well-trained surgeon must have a good knowledge of the structure of the human body in health and disease. This is one branch of medicine where knowledge can only be acquired through apprenticeship — that is, the learner needs to be guided by an expert. It takes many years and much exposure before a graduate in medicine can safely perform surgery. It is an aphorism in modern medicine that a surgeon needs to know not only how to perform surgery, but when. Importantly, the surgeon needs to know when not to perform surgery, a skill commonly called clinical judgement. These skills are difficult to teach and difficult to master.

Errors in surgery can be devastating. Data from the United States suggests that up to 4,000 surgical errors occur each year despite well-considered controls on who can perform surgery. Efforts to reduce this rate focus on better training. Besides professional codes, legal mechanisms have been developed to ensure safe medical practice.

In India, the Consumer Protection Act serves as an incentive to modern medical practitioners to provide high quality health care. Even this legal mechanism is not accessible to the poor. It is quite clear that there is no shortcut to safe surgical outcomes. One simply cannot get away from it — safe surgery requires years of training.

The idea of competence without comprehension should not beguile us into believing that surgery is a suitable subject for its application. Anecdotes of people not educated, but able to perform complex tasks should be understood in the framework of the psychologist Rasmussen’s Skill, Rule and Knowledge-based Error model. Some complex tasks are a set of repetitive steps where the person acquires proficiency merely by practice, for example, using a complex machine without knowing how it works. This is not applicable in surgery where novel situations are often encountered and a good knowledge base is essential to solve problems which may not have been previously encountered.

What constitutes safe surgery

Modern medicine is an integrated whole in which specialties have developed from the understanding that the knowledge base is so vast that a single human can only ever hope to master a few of the domains required in order to provide the best possible outcomes to patients. Modern medical training consists of a basic degree during which the fundamentals of the functioning of humans in health and disease, and techniques to diagnose illnesses are taught. Increased knowledge in various domains is obtained through post-graduate training. All these domains work together in order to ensure safe surgery. It is impossible for Ayurveda to incorporate surgical techniques while ignoring all the other domains of modern medicine and still perform surgery safely and effectively.

What is scientific knowledge? How is it to be transmitted? Is there any sound basis for different scientific systems in the modern world? More specifically, can there be fundamentally different explanations of how the human body is structured and functions? These are all important questions and have implications for policy in health care. Important decisions with potential to seriously harm thousands of people should not be casually made without clear answers.

Safe and effective health care should not become a casualty of a misguided desire to protect indigenous systems. Traditional knowledge in India has become the victim of self-serving apparatchiks who have fossilised it, preventing its development and growth. Human knowledge is a universal resource, ever growing. The way forward is to incorporate traditional medical systems into modern medicine.

Could deepen inequity

The quality of medical care received in India is highly dependent on personal resources. Surgical facilities manned by graduates of Ayurveda will be patronised only by the very poor who do not have the resources to access modern medical care. This will further entrench the existing grossly unequal access to health care. An epidemic of catastrophic complications, disproportionately affecting the poor can be expected if surgical procedures are performed by the poorly trained.

There is a shortage of trained medical personnel in rural areas. The only way to address this is to greatly increase the number of government medical colleges. This will take a few years, but it is a safe and effective policy. Safety of patients should not become a victim of misguided policies based on poor understanding of what safe surgery requires.

Dr. George Thomas, an orthopaedic surgeon practising in Chennai, is the former editor of the ‘Indian Journal of Medical Ethics’

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Printable version | May 7, 2021 2:06:14 PM | https://www.thehindu.com/opinion/op-ed/a-misguided-policy-that-cuts-deep-into-patient-safety/article33216050.ece

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