In the letter columns of the Stabroek News a debate has been raging among health care activists and medical practitioners as to whether a medical practitioner who holds an MB BS or an MD from a medical school is authorised to hold himself out to be a surgeon and to perform such surgical procedures as he/she claims to be competent to do.
Dr M.Y. Bacchus who is the chairman of the Medical Council of Guyana in response to one of the letters said that having obtained the MB BS "the doctor now has to be trained in the various disciplines before he/she can undertake any surgical procedure." Also he said that before he/she has completed the post-graduation training in the "various disciplines before he/she can undertake any surgical or other procedures, the doctor cannot tell patients that he is a surgeon and collect fees from patients for work done to them in the field of surgery."
In the same letter Dr Bacchus did indicate that the Medical Council maintains a register of doctors with post graduate diplomas in surgery "this does not mean that doctors who are trained, but do not possess a post graduate diploma - cannot perform skilful surgery. This is done all over the world - and in teaching centres."
He observed, "to deny such surgeons recognition of their work to society would be unjust."
Bryan Mackintosh the most prolific of the letter writers on this topic and who himself has suffered at the hands of surgeon, points out that according to the Medical Practitioners Act even though a medical practitioner "cannot legally call himself a surgeon, he is indeed allowed by the Laws of Guyana to perform surgery."
Prior to independence to be qualified and recognised as a surgeon a medical practitioner had to be trained in an institution recognised by the colonial administration and further certified by one of the Royal Colleges of Surgery. Any other qualification was considered wanting and to the susceptible colonial population this was interpreted as meaning that only someone trained and recognised by the British was a competent surgeon.
When Guyana became independent, the status quo changed and a surgeon was recognised by the fact that he or she held the certifying qualification of one of the established certifying bodies of the country in which he worked and studied. The present Medical Practitioners Act recognises a surgeon based on the fact that he or she is recognised by the certifying body of the country in which he obtained his or her surgical qualifications.
The origins of the debate
The present debate over who is qualified to practise surgery in Guyana seems to arise from the fact that unlike the pre-independence period, doctors practicing in Guyana have been trained at medical schools in the United Kingdom, the United States of America, at the University of the West Indies in Jamaica, the former Soviet Union, Cuba, and over the past decade or so at the University of Guyana.
Because old habits die hard and independence per se did not rid us immediately of all the colonial hang-ups, to be qualified to practise surgery medical practitioners were still required to be certified by one of the Royal Colleges after a period of training as being qualified to perform surgery.
Thus the medical degrees of MB BS or MB B Chr did not qualify a doctor to function as a specialist in medicine or surgery and he was and still is required to undergo a period of training and a peer review which takes the form of the examinations of the various Royal Colleges to be eligible to practise surgery. The same applies to doctors who studied in medical schools that awarded the MD as a first degree. Depending on the programme covered in the first degree the period of training for specialisation varies.
Another consideration is that many doctors practicing locally following their first degree never pursued formal surgical training in an established system but received local training.
These doctors despite their competence cannot be registered as surgeons under the present Act.
There have been rare cases where despite having the necessary qualifications, an institution may choose to offer a doctor a position not commensurate with his or her qualifications. Sources with whom Current Affairs have discussed the issue attribute these cases to the result of a demonstration of poor training on the part of the doctor or simply protectionism and support for a specific school or college.
Informed sources refer to another factor which occurred during the mid-eighties which gave recognition to doctors who were able to successfully perform procedures of increasing complexity on their own, after first observing and then doing some procedures under supervision.
The concern now is how an unsuspecting public could be protected from those medical practitioners who hold themselves out to be surgeons and are not qualified to practice.
Current Affairs has been able so far to explore this issue with the Director of Medical Services at the Georgetown Public Hospital Corporation, Dr Madan Rambarran, and Dr Surendra Persaud, Director, Medical Services at the St Joseph's Mercy Hospital.
The GPHC is a teaching hospital and the largest public hospital. St Joseph is the largest private hospital. In a subsequent article, Current Affairs will explore the need for a review of the Medical Practitioners Act.
Patients have to take responsibility for their care and cannot be absolved of the responsibility of being their best advocates. This is the view of Dr Surendra Persaud. He also says that they have a responsibility to check the doctor's qualification to offer the care which they are seeking.
Dr Persaud has been at St Joseph for about two years and is a relatively new kid on the block.
He was trained in the United States of America where he completed his surgical residency at New York Hospital, Queens in 2001 and practised for a year before returning to Guyana.
Obtaining a second opinion
Reacting to the debate about what qualifies a medical practitioner to hold himself out as a surgeon at the invitation of Current Affairs Dr Persaud stresses that it is important for patients to obtain a second and even a third opinion before undergoing any elective surgical procedure. He defines "elective surgery" as any surgical procedure that is not being performed on an emergency basis.
He defines emergency procedure as one which is urgently required and even then he believes in most of these cases there is still time for another opinion.
He observes though that getting a second opinion could be dangerous, as the patient may not like the information they are given and could be tempted to shop around.
Dr Persaud advises that patients should always obtain a copy of their medical records from their doctors, which is their property and which they are entitled to see at any time, so as to review it with the assistance of another physician.
He said that while the practice of getting a second opinion is the norm in the USA, he has found that it is the exception in Guyana.
However, he says that patients here are now beginning to appreciate that they need to inform themselves about their illnesses.
Aware of the awe in which some patients hold their doctors and the attitude of some doctors when told that one wishes to seek a second opinion, Dr Persaud says that obtaining a second opinion has noting to do with criticism and for him, "the more informed my patient is the easier is my task."
Credentialing procedures
Asked to comment on the procedures that St Joseph has in place to ensure that the surgeons associated with the hospital are competent to perform the surgical procedures that they undertake, Dr Persaud said that it is the hospital's responsibility to have policies and procedures in place to credential surgeons. At St Joseph, he says, the procedure requires the doctor applying to be employed as a surgeon to provide information about his qualifications, the institutions where he has worked and the names of persons who can attest to his competence.
He says that the hospital may seek clarification if necessary about some aspect of the information he has provided and the package is then sent to a committee comprising medical and administrative staff which would then make a recommendation to the hospital's board for its approval. If the decision is to recruit the doctor as a surgeon, he/she is placed on probation which lasts for about three-six months depending on his/her experience.
Review procedures
Dr Persaud says too that there is a system of oversight in place which is the conference on morbidity and mortality that looks at the outcomes of all surgical procedures performed at the hospital so as to track if there is any casual circumstances, which he defines as "unexpected complications."
He explained that any work done in medicine has risks and that these risks have percentages attached to them and the conference looks to see whether their findings are above and beyond these percentages.
He advises that before agreeing to surgery, patients should have their doctors inform them of the risks, benefits and the available alternatives to the procedures they are being told they need to undergo.
As a teaching hospital, the procedure at the Georgetown Hospital is different. Students at the UG Medical School do all their training there from the second year of their programme to their post-graduation internship.
During the medical school programme they are supervised by their tutors and after graduation they are supervised by senior doctors.
Those who pursue specialised training in surgery, according to Dr Rambarran, do so under the supervision of a specialist, whose name appears on the patient's chart as being responsible for the person's treatment, even though the junior doctor is the one dealing directly with the patient.
Because the specialist's name is at the top of the chart, he/she takes the responsibility for the procedures carried out by his/her junior, to whom he gives increasing responsibility as his/her competence increases.
The specialist accepts that responsibility even when not physically present at the time the procedure is being carried out.
Importantly, however, the specialist is available to offer advice about dealing with any complication that arises and if necessary to step in and take over the procedure.
Dr Rambarran also says too that the review mechanism is the morbidity and mortality conference which reviews the patients' care to see if any problems that arose were due to things that had been done or not done and if the omissions were explainable.
Additionally, Dr Rambarran says that audits of outcomes are done and that over the last eighteen months they were being used as part of the process of tracking, evaluating, analyzing and interpreting the results for research purposes.
Private practice
Both Drs Persaud and Rambarran agree that the cover a doctor has in an institutional setting is not available if he/she is in private practice and decides to carry out the procedure at his/her surgery.
Dr Persaud lives by the words of one of his professors at medical school who said that if you are doing a procedure where two hands are not enough that procedure should be done in a surgical centre.
He says that these centres could be outside the setting of the hospital and would expect the Ministry of Health to regulate them so as to ensure that they are properly equipped.
He said that he understands that because of the lack of resources people may be unable to approach a private hospital for the care they need which may not be available at the public hospital and may seek care at alternative sites. As a consequence, he says, there is a need for private surgical centres, which he says must be properly equipped and regulated.
Dr Rambarran says that standards should be set for "office procedures" and an inspectorate set up to licence those offices which meet the required standards.
He noted that the Medical Council had issued an advisory about the equipment which should be on hand when certain procedures are being carried out in a doctor's office.
The Council issued the advisory following a number of deaths which occurred during procedures that were carried out in doctors' offices which did not have the required resuscitation equipment.
Dr Persaud, who is an old boy of Queen's College and returned home when doctors his age are leaving at the first opportunity, explained that medicine is a calling and if a doctor is in it for the money he is in the wrong field.
Asked about the question of remuneration which most doctors give as one of their reasons for leaving, Dr Persaud explained that a doctor earns at an average three times or more the salary of the man in the street.
Also he says if his salary is converted into US dollars the doctor would always be disappointed.
About the cost of heath care in Guyana Dr Persaud says that it is still one of the most expensive things on which people spend their money.
State of surgery
Commenting on the state of surgery in Guyana both doctors say that there has been the introduction of a number of new procedures and Dr Rambarran says that preparations for introducing others are ongoing.
For instance he said that GPHC is in discussions with overseas-based physician Dr Kishun Narine who is at the University of Ghent about establishing an operation and diagnostic site where patients could be treated for blocked arteries and diseased valves, conditions which are related to diabetes and hypertension. At present he said that pharmaceutical intervention is the way to treat patients with these conditions.
He said that it should take some twelve months to acquire the hardware for the unit which should cost some US$1.5 - $2 million to acquire.
Dr Rambarran said that GPHC is also looking at being able to provide some laproscopic procedures for doing hernia repairs and appendectomies among others.
He said that because the procedures are minimally invasive patients spend a shorter time in hospital. St Joseph is already offering some laproscopic procedures.
And to clear the backlog of patients, most of whom are aged, waiting for eye surgery, Dr Rambarran said that GPHC is collaborating with ORBIS, an international agency for eye diseases, on a three-year project to reduce the list.
He said that the operations would enable the older patients to have a better quality of life.