Viewpoint

Introduction

The way a doctor dresses is a fundamental part of establishing therapeutic alliance with patients.^1,2 It has been shown that doctor’s dress can influence patient confidence, offer greater reassurance, higher levels of trust, better adherence to prescribed medication regimens, enhanced willingness to complete return visits, and discuss sensitive issues.^3,4 The literature outcomes in this field are mixed; for example, some studies suggest a non-correlation with perceived courteousness or professionalism,^5,6 but we believe there is enough evidence to suggest that the manner in which a doctor dresses forms an important part of non-verbal communication, which is important for their interaction with patients, carers and with other staff members.

Various studies have examined patient preferences towards doctors’ dress. Formal dress or a white coat have been cited as favoured due to their perceived association with empathy, competence and trust.^2,4,7,8 This is in contrast to other studies which found semiformal dress as preferred.⁹

In psychiatry, studies of inpatients have indicated a preference for smart attire and white coats as part of their doctors' dress code.^10,11 Mcguire et al also found that community patients preferred their psychiatrists to be dressed as “smart/formal”.¹²

In recent years, dress code policy for doctors in the UK has become more informal, and white coats have been abolished for a number of reasons.¹³ In this study, we sought to determine the attitudes of multiple stakeholders towards doctors’ dress in both general and psychiatric hospital settings.

Methods

We surveyed healthcare staff, patients, and carers in an emergency department at a district general hospital (“medical setting”), and in a psychiatric hospital (“psychiatric setting”) in the South East of England. The data was collected on a week day between 09.00 and 17.00 at both settings, using a questionnaire based on Rehman et al.¹⁴ There were no exclusion criteria.

The survey questionnaire sampled demographic details, and used nine questions and two sets of images (a male doctor & a female doctor) depicting three styles of dress; white coat, formal (tie & trousers for male; dark skirt and white shirt for female) and smart casual (“bare below the elbows”). The survey questionnaire was piloted amongst volunteer staff and assessed for their user-friendliness and ease of comprehension before use. It was amended in line with the feedback received.

Results

337 individuals responded to the questionnaire, giving a response rate of 94%. Our sample was predominantly white (72%), female (62%) and married (43%). Respondent age, ethnicity and employment status were broadly representative of the local population.

Overall (Table 1), we found that the majority of respondents felt that the way that doctors dress was important to them, and that the location of respondents significantly affected their preferences (p <0.001). Although in these overall results there was no majority preference for one dress code over another in either location, preferences within each varied significantly (medical: p<0.01 and psychiatric: p<0.001). This numerical preference appeared to be for formal dress in both settings, capturing 35% and 45% of respondent vote respectively.

Within the three stakeholder-specific breakdowns (Tables 2-4), differences in preference reached significance for medical staff (p<0.001), psychiatric staff (p<0.001), psychiatric patients (p<0.05), and psychiatric carers (p<0.01). Like the overall results, there was no majority preference in any of these groups, but formal dress captured the highest numerical vote in medical staff (41%), psychiatric staff (55%), and in psychiatric patients (41%). Psychiatric carers preferred formal and smart casual dress broadly equally, which captured 36% and 40% of the vote respectively. Carers were the only stakeholder whose preferences were significantly influenced by their location (p< 0.01).

Dress code statistically significantly influenced the attributes associated with the doctor wearing them (p< 0.0001), as shown in Table 5. Formal dress captured the greatest proportion of every attribute tested, and considering total responses, formally dressed doctors were almost twice as likely to be associated with these attributes as those dressed in smart causal or a white coat.

52% of respondents were not aware that a doctors’ dress code policy existed, and while 53% of respondents felt they should not be consulted when considering dress code, 41% believed they should. 59% of respondents believed doctors adhered to their sites’ dress code policies, while 27% did not think so.

Discussion

To our knowledge, this is the first study in the world to compare preferences in doctors’ dress code between a psychiatric hospital and a medical hospital. Also, no other study to our knowledge has simultaneously explored the attitudes of different key stakeholders in both medical and psychiatric settings regarding this important issue.

In this study, we have successfully captured the attitudes and perceptions of key stakeholders regarding doctors’ dress code. We found that overall, doctors’ dress code was felt to be important, and that in medical and psychiatric locations a formal dress code is preferred. Looking at staff, patients and carers specifically, we found a preference for formal dress among medical staff, psychiatric staff, and in psychiatric patients. Among psychiatric carers, formal dress was preferred equally to smart casual. There were no significant preferences among the other stakeholders surveyed.

This preference for formal dress is easily explained by the results shown in Table 5. Seeing a doctor in formal dress made it almost twice as likely that that doctor would be seen as possessing any of the eight positive attributes included. Clearly, in the eyes of the respondents to our survey, a formally dressed doctor was most likely to provide good care. 

Table 1. Dress code preferences among all stakeholders. P values were calculated using Chi-squared test. NS = not significant (p=>0.05).

Table 2. Dress code preferences among staff. P values were calculated using Chi-squared test. NS = not significant (p=>0.05).

Table 3. Dress code preferences among patients. P values were calculated using Chi-squared test. NS = not significant (p=>0.05).

Table 4. Dress code preferences among carers. P values were calculated using Chi-squared test. NS = not significant (p=>0.05).

Table 5. Doctor attributes associated with different dress codes.Respondents were shown images of each dress code asked “Which doctor would you…”: Trust the most (trust), Follow the advice of (advice), Have confidence in their diagnosis and treatment (conf.), Return to for follow-up care (return), Regard as knowledgeable & competent (knowl.), Regard as caring & compassionate (caring), Regard as responsible (resp.), Regard as authoritative & in control (auth.). P <0.0001.(calculated using Chi-squared test). Results were excluded for where more than one dress code was selected for an attribute, or where no choice was made.

Discussion (continued)

Interestingly, we also found that the location of healthcare influenced the preferences of carers to such an extent that it offset the non-significant results among staff and patients; such that this significance was carried through to the overall results. Exploring this in more detail, we see a marked preference for smart casual in the psychiatric setting over the medical setting (40% vs. 13%), for a white coat in the medical setting over the psychiatric setting (33% vs. 11%), and an almost equal preference for formal dress in both. This starkness in difference in preference between care locations indicates differences in the cultural perceptions of doctors by carers, but not by staff or patients. Perhaps an explanation for this difference is that historically, carers have been more involved and influential in the psychiatric setting, being an essential component to care, whereas in the medical setting they have tended to be more passive partners in care. A negative perception of mental health care portrayed to the public through film and media may have driven preferences away from white coat in the psychiatric setting, whereas in the medical setting perhaps a positive association with the white coat and physical health may have done the opposite.

Conclusion

We have identified a clear preference for a formal dress code for doctors from all stakeholders at medical and psychiatric care locations studied. However, we identified several interesting variations in preferences among individual stakeholders, and found that the location of care significantly impacted the preferences of carers. We believe these findings could be harnessed in the future development of dress code policies for doctors in order to enhance the doctor-patient relationship, and to improve the quality of doctors’ relationships with both carers and with other staff members. Additionally, there may be merit in involving these stakeholders during the policy development process.

Introduction

Medical scientists who espouse a strict biological model of the mind tend to care less about the prolongation of life than do those who have faith in higher authority.¹ The prevailing reductionist model of mind has recently been challenged effectively.^2,3,4,5. That has led to a position in which there is some justification for claiming that there is scientific evidence to enable a suspension of disbelief in life after death. ⁶ Medical profession should respect the theology veiled in thanatology and should be careful not to become instrumental in creating a culture of death; alleviating suffering is not by eliminating the patient.

In the absence of spiritual conviction, human suffering lacks deep meaning and death is regarded as the ultimate tranquilliser. Prolonging life at any cost may be perceived as a worthless endeavour. To counter that, without suffering evolution would not take place and human consciousness would fail to expand. Without stress and struggle the spirit buds to which we may be likened would not mature and grow leaves and fruit, and our characters would not develop; we would lead the lives of lotus-eating sybarites. ⁷

Evidence for discarnate survival

According to those who are sceptical about after-death survival, there is only as much evidence to justify belief in life after death as there is for the historical existence of dinosaurs. Some scientific researchers however argue that there are compelling reasons to support those who are proponents of belief in life after death. Dr Vernon Neppe, a neuropsychiatrist turned parapsychologist, has declared that the combined body of evidence for discarnate survival is overwhelming – so great that it may be regarded as scientifically cogent.⁸ This emerging scientific view, coupled with the wisdom of the faith traditions, challenges the rationality of supporting assisted suicide. The following are examples of evidence for discarnate existence that are commonly cited:

• clinical death experiences
• pre-death visions
• shared death experiences
• collective apparitions
• some forms of mediumistic incidents, particularly ones that involve cross-correspondence, drop-in communications and physical phenomena
• children’s memories of previous lives
• electronic voice phenomena
• instrumental trans-communications
• transplant cases
• Scientifically studied Marian apparitions

The list is becoming longer as survival research progresses. Encouraged by the success of afterlife experiments with mediums,⁹ the multi-specialist professor Gary Schwartz of Arizona University claims to have invented a device to communicate with discarnate spirits; the holy grail of survival research that could possibly offer a fool proof scientific evidence of afterlife existence,¹⁰ but also takes account of all the potential negative consequences. He claims to have worked with black boxes in his laboratory, using a software programme that has generated proof that there is a spirit world by measuring light. ¹¹It appears that he has developed a technique whereby faint light can be detected in a totally dark box. Measurements are taken at the beginning of an experimental session, and then a specific “hypothesized spirit collaborator” is asked to show a “spirit light” in the box and a second reading is taken. The finding is that instruction for specific spirits to enter a light sensing system was associated with reliable increase in the apparent measurement of photons. Such a curious result means that these communicating spirits are able to hear, respond and produce light in an otherwise dark enclosure. ^12,13 The conclusion is that survival research opens up new vistas which seem much more important than cosmology or quantum electrodynamics.

Scientifically examined Marian apparitions are a recent addition to the evidences for discarnate existence. ¹⁴ Mainstream scientists seem never to have attempted to develop the conceptual tools and vocabulary needed to investigate the possibility of post-mortem existence. It may be that science will not accept the possibility of discarnate survival without a new theory of physical reality. In the early part of the twentieth century the prevailing view of scientists was that there was no possibility whatsoever of proving the existence of life after death. Over the years that have passed since then attitudes have evolved, and in the world, we are now in it is asserted by some researchers that there is scientific evidence for the existence of life after death. Some of the evidence relating to discarnate existence may not however satisfy the criteria of the physical sciences since the latter are based on speculative science and court room logic.

Paradigmatic shift

Demonstrating post-mortem existence as an irrefutable phenomenon is a route to establishing empirically that humans have a higher consciousness. Unfortunately, in survival research there are many phenomena that have multiple possible explanations, and these augments add to the complexity of this immensely significant area of scientific enquiry. All the types of evidence postulated as supporting discarnate survival are simultaneously a form of evidence of a non-biological component that operates in association with the brain. The existence of a non-biological component indirectly proves the possibility of survival after physical extinction. A huge paradigmatic shift towards non-reductionism is now taking place in the cognitive sciences – consciousness is no longer considered an epiphenomenon of brain activity, but asthe designer and prime mover of the material body. Nowadays, some mainstream scientists are themselves paradoxically trying to debunk mainstream science.

Suicide victims

Through suicide, a person is simply changing the location of their suffering. While wrapped in the physical planet by space and time, we are in an advantageous position for inducing personality changes swiftly, whereas in the timeless state of discarnate existence changes are sluggish and personality development is much slower. Contemporary data for survival research may be congruent with the wisdom of the faith tradition. ¹⁵ To use a simple analogy for this, carrying out assisted suicide is like destroying the shell of a pupa and forcefully freeing it in a premature state. Such a pupa will not be able to fly about like a butterfly. It is arguable that a person subjected to violent death – as in the case of suicide – may not be able to enjoy the beauty of God’s grand other-worldly dimensions until they have become spiritually compatible with them. They have to navigate through the physical plane like wingless birds. ¹⁰ To look at this way, if fruit that is unripe drops from a tree, it will be sour. Suicide breaks a solemn law because it deprives the conscious self of the natural growth that life in a physical body can best provide.⁷The Chinese saying “One day of earthly existence is not equivalent to a thousand days of ghostly existence” is a statement of the sanctity of terrestrial life.

Lord Alton has campaigned against the Assisted Suicide Bill of 2014 since its inception. Referring to his dying father’s account of how he had seen his own brother, a member of the Royal Air Force who had died in the Second World War, Lord Alton argued that a forced death, as opposed to a natural one, may deprive a person of their “healing moment.” ¹⁶ A graceful and natural death may be supposed to be accompanied by benign caretaker spirits with exuberant love who assist those who are dying by making them comfortable for the big transition.^17,18 A person who terminates their own life prematurely may not be so fortunate as to get such benevolent assistance from the spiritual realm. Most hospice workers are very familiar with departing and death-bed visions such as that described by Lord Alton. Furthermore, it has been suggested that beings from the imperceptible spiritual sphere who assist in delivery from the terrestrial plane have a role in such matters as the timing of death, and it is arguable that their part in what happens should not be impeded by intervention.

It appears that human brain is designed to have some doubts about discarnate survival for some reason and a fool proof evidence of post-mortem existence may have its down side in that somebody who is fed up of life might use it to justify ending his earthly life voluntarily. ¹⁹An ultra-optimistic view of discarnate life is spiritually counterproductive and such an over optimism could be seen as a justification by the patient and carers in the decision making of assisted suicide. In a weak moment of extreme psychological or physical sufferings, such a belief can also become the final rationalization for ending one’s own life voluntarily. In my own clinical practice, I have come across suicidal patients telling me, “It will be always better on the other suicide.” A belief in discarnate existence based on parapsychological proof alone did not deter one such patient making a serious suicidal attempt

End-of-life concerns

The evening of life was considered as a great opportunity for spiritual, emotional and psychological growth and a celebration of one’s life journey. These are also times to harvest the wisdom of yesteryears and share them with the succeeding generation. Spiritually enlightened people consider this to be the time to conquer the fear of death. Fear of death is not the fear of the physical pain of death, but the fear of truthful self-judgement after death. Recent observations in thanatology favour a belief in post-mortem self-assessment and appraisal. For some, it would be voluntary or assisted, whereas for others it could turn out to be forced upon them. The final phase of life is the time to settle the errors committed against fellow beings that have not been remedied in life. Fortunately, modern medicine has prolonged this period, which grants an opportunity for most people to experience conscious ageing. Sadly, traditional attitudes towards the evening of life have changed in today’s youth-obsessed culture. For some, medical procedures have extended life and made dying a lingering process rather than a sudden event, and have contributed their own problems. For several reasons, terminally ill people who are in crisis may wish to die rather than being kept alive longer (Table 1).

From an evolutionary point of view, there can be only a survival instinct – no Freudian death instinct. Avoiding death rather than seeking it is a natural human urge and the fear of death may affect every individual action. The very concept of euthanasia is totally against the human make-up and is entirely artificial. Assisted dying and assisted suicide are the same thing when a member of the medical professional gives a lethal drug to a person so that they can take their own life. Euthanasia is different; it happens when, for example, someone injects a lethal substance into a patient. Involuntary euthanasia refers to a situation in which the patient has the capacity to give consent, but has not done so; and in non-involuntary euthanasia a person is unable to give consent, for example because of dementia or being in a coma. Mercy killing is claimed to be a compassionate act to end the life of a patient.

Table 1: End of Life Concerns

1. Losing autonomy
2. Less able to engage in activities making life enjoyable
3. Loss of dignity
4. Burden on family, friends/caregivers
5. Losing control of bodily functions
6. Inadequate pain control or concern about it
7. Financial implications of treatment

Moral and ethical issues

It has been observed that the risk of suicide is higher among people with a family history of suicide. Family culture and genetics may account for the increased incidence of suicide in such situations. Assisted suicide would create a trail in the culture of more families and more succeeding generations would perhaps be at increased risk of considering suicide as a serious option at a time of crisis. Kevil Yull (2013) comments that changes in the law of assisted suicide would have an additional impact on those left behind, because of their effect on the moral connections, assumptions and accepted responses to situations on which we base our relationships with fellow human beings and establish ourselves in the world. ²⁰ He argues that the legalisation of assisted suicide would undermine freedom instead of promoting freedom of choice, and also that the proposed safeguards and regulations would breach the privacy of the death-bed.

Assisting someone to kill themselves is assisting them in murder. According to all the major faith traditions, life is a gift from God and ending it is like throwing a precious object back to the giver. All spiritual traditions teach and believe that bringing the human heart to a standstill is God's business (Table 2). There are patients who assert that even if all their limbs were amputated, they would still want to hold on to the treasured gift of life. It is very difficult to define what unbearable suffering is; extreme suffering is a subjective matter that it is not possible to separate from an individual’s outlook on life. A fundamental question is that of who would be the one to pronounce a verdict on when suffering is intolerable – the patient or medical personnel?

Laws are not precision-guided arrows and they may become perverted. In a world full of violence and crime, assisted suicide is unsafe and could be exploited. There would be many unintended consequences. For reasons of public safety alone, some people oppose assisted dying. Financial abuse by relatives of the elderly seems to be becoming more common; those with a vested interest could be tempted to put an inheritance before life.

The regulation of assisted dying has been modified in recent times in some countries, an example being the Netherlands in 2014. There it is now lawful to kill a patient without their consent, and euthanasia and assisted suicide may be offered to people with mental health problems (consensus with the family is required in all these situations). Inboth Belgium and the Netherlands the euthanasia of children is legal with family consent (in Belgium there is no age limit; in the Netherlands the child must be 12 or above and must give consent). In Belgium blind adults who were developing further problems were granted euthanasia at their own instigation a few years ago. There is public concern about collaboration between euthanasia teams and transplant surgeons in Belgium.

Table 2: Medical dilemmas

1. Assisted suicide promotes a human right to commit suicide and gives wrong messages to suicidal patients in psychiatry. 
2. It undermines the Universal Declaration of Human rights and strikes at the foundations of all spiritual values. 
3. It is hard to define unbearable sufferings. 
4. Assisted suicide has many unintended consequences. 
5. Death with dignity could deteriorate as death with indignity. 
6. It might permit the unlawful killing of innocent people in certain circumstances. 
7. It is founded on unethical principles-survival of the fittest.      

In 2013, 1.7% of all deaths in Belgium were hastened without the explicit request of the patients. ²¹ Professor Cohen Almagor, the author of 2015 report on euthanasia in Belgium stated that the decision as to which is no longer worth-living is not in the hands of the patient but in the hands of the medical personal. ²² More than 500 people in the Netherlands are subjected to euthanasia without their consent.²³ Data from Oregon where assisted suicide was legalised in 1977 shows that the top five reasons people choose assisted suicide are not because they are suffering from a terminal illness and 49% stated that feeling like a burden and a fear of loss of control are among the main reasons for choosing assisted suicide Oregon .²⁴ In Washington state in 2013, 61% of people who were killed in assisted dying said that being a burden was a key factor for their choice of death. ²⁵

Medical Dilemmas

Majority of British medical practitioners are against assisted suicide. ²⁶ A 2013 survey showed that 77% hold the view that they would oppose a change in the current law to allow assisted dying, 18% favoured the RCGP moving to a neutral position, and only 5% favoured a change in the current law. They opined that a change in the law would make patients afraid of their doctor and would alter doctor –patient relationship, and would make vulnerable patients most at risk from assisted dying. According to Marris bill, some people should be given help to die meaning that some lives are worth less than others. Vulnerable people would feel pressurised to choose death and could be killed without their explicit consent. GPs feel that it is their privilege to protect the disadvantaged and vulnerable people of the society.

Assisted dying would lead to less focus on investment in palliative care. The RCGPs also cautioned in the survey that a change in the position of the law makers would become like abortion legislation, which started as something for extreme circumstances and is now effectively on demand. They are also anxious for the fact that legalisation of assisted dying would make it impossible to tell the real reason why patients decided to die, because illness can cause people to become depressed and frightened. As debate on assisted suicide has become hotter, in clinical practice suicidal patients have already started enquiring about the prospects of assisted death.

Thanatology

Medical sciences have not advanced enough in matters of death to offer details to make informed choice for those who want to die voluntarily and thanatology is only a fledgling science. Thanatology is the scientific study of death and investigates the mechanisms and forensic aspects of death, such as bodily changes that accompany death and the post-mortem period, as well as wider psychological, parapsychological and social aspects related to death. They are not particularly interested in the meaning of life and related philosophical issues, but this is an area where science and philosophy not be separate. In recent years, studies of parting visions by Elizabeth Kubler Ross and Raymond Moody’s NDE studies. ^{27,28,29,30,31,32} have given a spiritual dimension to thanatology. Theology and Thanatology are two major corpuses of human wisdom that cannot but overlap. Assisted dying would probably become also an issue of forensic sciences.

It is the job of the doctor to keep the patient alive whereas it is the job of the psychotherapist to have a sense of a bigger picture. ³³ People wanting to hasten death should also have the choice of receiving pastoral and psychotherapeutic assistances to distract themselves from their preoccupations of death and allow nature take its own natural course. New generation psychotherapists will have to be well versed in all aspects of death related sciences. Thanatology has a rightful place in medical studies, but I content that medical professionals need not to be unduly concerned about the different forms of afterlife existences, the borderland between religion and thanatology. Medical professionals are expected to be above religion and politics. Thanatologists now fear that if assisted suicide is legalised, they might be pressurised to slip from the original goal of acquiring more knowledge of human dying to serve the dying into the pursuit of death.

Concluding Remarks

Assisted suicide or euthanasia is incongruous with the theological view that it is the weakest and the vulnerable who can teach us the values of life and the concepts of euthanasia or assisted suicide have an indirect message of discarding them. The right to die would soon deteriorate as duty to die to prepare room for fittest ones. Instead of looking for reasons to live, people will be looking for reasons to die. What is need is better understanding of death process and advancements in the palliative care of the terminally ill, rather than doing away with them. Until we know more about the death process, assisted dying debate should be kept on hold. More research in palliative care and allowing people to die naturally with dignity should be the concern of medical profession.

Evolution may be taking place in biological and spiritual streams and they are interconnected: biological sufferings maybe aiding spiritual evolution. ³⁴. From a philosophical perspective, the rationale of terminal sufferings is to help the individual to disengage from the “pleasant illusions” of earthly life. The debate of assisted suicide raises the question whether human beings are mere electrical animals, quantum beings or fundamentally spiritual personalities-humans maybe all the three.The sanctity of human sufferings need to be brought into the equation of assisted suicide discussion. Assisted suicide would only add to the growing violence in the present world that could do with reintroduction of principles of non-violence.

USA may have better legal infrastructure to negate the unwanted and unintended errors of assisted suicide, but in many third world countries, where there is no such legal infrastructure, the procedure would easily get dishonoured. Oriental religions as well as Abrahamic faith traditions are opposed to ending life voluntarily. In general, all faith traditions believe that life that is nearing the biological end need not be preserved at all costs and that one does not have to go to extraordinary lengths to preserve a terminally ill person’s life. This means, for instance, that while a terminally ill person should not be denied basic care, he or she could refuse treatment that might prove to be futile or unduly burdensome for the dying person - passive voluntary euthanasia.

A scientific belief in after death existence is not without its pitfalls unless it is accompanied by the spiritual corollary of sanctity of earthly life. Science alone cannot highlight the sanctity of life; Divine standards are helpful in comprehending the sacredness of life. In fact, science has taken us to a cross road with Professor Schwartz’s new instrumental communication and it is time mark the boundaries of healthy survival research and the unhealthy ones.

Introduction

The closure of asylums in the last century has resulted in an increased number of compulsory hospital admissions for psychiatric patients. Psycho-geriatric patients are highly vulnerable in this respect. Although the traditional buildings instituted for the care of the mentally afflicted have gone, misconceptions about provision and anecdotes about incarceration continue to haunt the community. Recent legislative changes have further extended the occurrence of involuntary hospital admission.¹ Compulsory community care is under constant review. Concurrently the validity of the concept of mental illness, psychiatric classification and diagnostic dilemmas all continue to be debated. Confinement has regained respectability in the discourses of present-day British mental health system because of violent offences committed by psychiatric patients and the public media portraying them as a reflection of failure of community care.

Table 1, Advantages of Mental Health Acts

Numerical quantitative studies imply that generally involuntarily admitted patients show clinical improvement and retrospectively view their compulsory admission rather positively.² It is an unquestionable fact that Mental Health Acts prevent suicides and homicides (table 1). Mental Health Acts have some unsatisfactory outcomes particularly on a subset of patients including senior citizens admitted formally. It is important to identify such patients and take additional precautions in their management as they run the risk of leaving hospital feeling inferior and inadequate. Patients’ specific characteristics, thought processes and past treatment experiences, colour their attitude towards coerced treatment and determine the gains and shortcomings of compulsory care.

Disadvantages

The Mental Health Acts are open to social abuse and elderly patients can be more defenceless in this respect. Specifically they may be: invoked to control behaviour; misused for material gain and implicated in subtle expressions of revenge. They are sometimes invoked to hasten divorce proceedings and to secure the custody of children by a specific parent. They are also used to control the behaviour of children by their parents. Mental Health Acts designed to control psychiatric patients are being enacted and enforced in some underdeveloped countries that lack an efficient tribunal system to monitor their effects.

A patient who has been detained is at risk of repeat detention and someone who has been inappropriately assessed becomes increasingly vulnerable to control on psychiatric grounds. The experience of being detained involuntarily has a reductive effect on behaviour after discharge – it may induce anxiety or post-psychiatric depression. The awareness of being deemed to require compulsory detention generates such negative attitudes as self-denigration, fear and unhealthy repression of anger. It may also impede self-direction and the normal sense of internal control and may encourage the view that in a world perceived as being divided into camps of mutually exclusive ‘normal’ and ‘abnormal’ people, the patient is in the latter category. Compulsory detention may lead to suicide because the patient loses their sense of integration within their own society. Furthermore, the fear and anxiety associated with involuntary admission delays the recovery process. There are other frequently occurring barriers to recovery for those affected such as, loss of capabilities, whether real or imagined, ineffectual medication due to poor elicitation of symptoms because of patient’s lack of cooperation and negative drug side effects.

Depressed patients have a higher suicide risk than the population at large and one of the reasons for detention is suicidality. Some of the subjective symptoms of depression can be ameliorated by denying them, while compulsory detention may reinforce depressive symptoms. Detention gives carers a false sense of security and this may lead them to relax their vigilance towards the patient. The Mental Health Acts increase the stigma associated with psychiatric illness and with the exuberant expression of emotions. Patients who are under section or are frightened of being placed under section may deliberately mask their symptoms in an attempt to have the section lifted or to avoid sectioning.

Trans-cultural studies

Trans-cultural studies show that members of migrated cultures, particularly the elderly, are more at risk of inappropriate sectioning than the rest of the population because of the lack of knowledge on part of professionals about the patient’s culture. For instance, the debate of over diagnosis of schizophrenia among Afro-Caribbean patients is still unsettled. A study conducted in South London has concluded that Black Africans and Black Afro-Caribbean patients with psychosis in that area are more likely than White patients to be detained under the Mental Health Act 1983.³ GreatBritain has become a multicultural society and a significant percentage of professionals working in psychiatric units have been trained overseas, in a wide range of countries. This creates further risk of inappropriate diagnosis. There needs to be more emphasis on the significance of trans-cultural psychiatry in the United Kingdom. In particular, psychiatrists should be aware that psychiatry is a medicine of language and culture as well as of the mind.

Medical Dilemmas

Countries in which Mental Health Acts are widely enforced have not achieved any reduction in suicide rates through their implementation. Sectioning is perceived by many patients affected as a psychological guillotine – a form of psychiatric terrorism. The medical profession is invested by the Acts with undue power over society. This is of particular concern because training in psychiatry does not include the study of free will and allied philosophical issues and also because there is no clear definition or description of mind and consciousness. In psychiatry there is a lack of clinical indicators and psycho-physiological parameters so the criteria for diagnosis are imprecise, with a concomitant risk of the Acts being erroneously implemented. It has been postulated that once a person has been classified as having deviant behaviour, that categorisation has a potent effect on the subsequent actions of the person concerned and those interacting with them.

Is it not justifiable to argue that even if a few mentally ill patients are underdiagnosed and not subjected to psychiatric admission, someone whom we would regard as normal should not be detained in a psychiatric hospital against their will? Such a view is analogous to the judicial view regarding capital punishment where even if ninety-nine murderers escape capital punishment because there is no death penalty, one innocent person should not be sentenced to death. Mental Health Acts may be a necessary evil but they present a dilemma for mental health professionals: the morality of helping patients and protecting the society from the consequences of their illness against the immorality of restricting their freedom. Clinicians become torn between the ideals of curing mental illness and defending the sanity of patients.

Patients’ Perception

A small survey conducted by the author revealed that no sectioned patient in the group studied sent a thank-you card after discharge to the ward in which they were confined. However, many voluntary patients expressed appreciation in that way. This is an indicator of the attitude of sectioned patients towards the Mental Health Acts. One reason must be that a record of being sectioned limits their freedom to travel and also affects their employment opportunities adversely. A patient has commented that it is easier for an ex-convict to gain employment than it is for a once-sectioned psychiatric patient.

There is anecdotal evidence illustrating the panic that may be generated with the word ‘section’ in psychiatric patients. A recovering elderly hypomanic patient explained that he misconstrued the word on hearing it when he was ill, taking it in relation to sectioning in Obstetrics and General Surgery. He remembered that as he resisted entering a taxi while being persuaded to agree to admission, the driver said that he was going to be sectioned if he refused hospital admission. The patient misunderstood this and interpreted it as he was going to be cut into pieces and tried to jump out of the vehicle.

Post-traumatic stress disorder

Any loss of intrinsic importance to an individual constitutes bereavement. Denial, anger and depression experienced in compulsory detention are comparable to bereavement.⁴ In the case of a detained patient, the loss of self-identity and of social functioning causes a grief reaction. It has been hypothesised that there are high levels of Post-traumatic Stress Disorder (PTSD) symptoms in detained patients.⁵ Very few repeat detainees become habituated to the implementation of the Mental Health Acts. The vast majority become increasingly frustrated and develop a pessimistic outlook towards their mental health. There is a high incidence of suicide among patients who have multiple detentions.

Post-hospitalisation Stress Disorder is much more common than generally recognised. Formal admission may lead to fear, anger, frustration, depression or loss of self-esteem, depending upon the individual’s psychological response.⁶ Involuntary admission may result in pervasive distress in any patient – this kind of hospital admission may be perceived as threatening and even as a catastrophe. Detained psychotic patients are less aware of their environment because of the preoccupation with their symptoms. Non-psychotic patients, when detained for instance because of a risk of suicide, are fully aware of their immediate environment and the chaos they have caused to themselves. They have a high risk of PTSD.

Preventive detention

Fear of liability may lead to compulsory hospitalisation solely to prevent violence on the part of patients who otherwise do not require in-patient care.⁶ Psychiatrists are not trained to police society and may lack sufficient knowledge and experience to participate in the social control responsibilities that are part of the remit of the criminal justice system - they are sometimes involved in that function. Psychiatry has to be safe and secure in the hands of individual psychiatrists and psychiatrists have to be protected when practising psychiatry. Mentally ill patients are sometimes mistakenly processed through the criminal justice system rather than the mental health system. When that happens, compulsory detention may be perceived as a form of criminalisation of mental illness. Unless there is scrupulous monitoring, mandatory treatment impinges on civil liberties. Preventive detention is legally ambiguous and clinically impractical.

Assessment

Amongst the government’s fundamental powers and responsibilities are, protecting people from injury by another and caring for less able people, whether physically or mentally incapacitated. These functions encompass the welfare and safety of both the individual concerned and the public.

A decision about compulsory detention is made on the basis of three considerations: loss of emotional control; psychotic disorder and impulsivity with serious thoughts, threats or plans to kill oneself or others. Any perceived risk must be imminent and provocative. The clinician is legally required to determine the least restrictive environment to which a patient may be safely assigned for continued care. To fulfil these requirements while implementing the Mental Health Acts, a psychiatrist needs the skills of a physician, lawyer, judge, detective, social worker and philosopher. The decision-making process is influenced by multiple factors such as: the clinician’s propensity to detain patients; the record of past untoward incidents involving the patient; attitude towards risk taking and availability of hospital beds and alternative safe treatment facilities. It is regrettable that in section 5(2) assessments, often it is a junior doctor, the least experienced person in the team, who is called upon to conduct the evaluation.⁴ A multitude of interviews with mental health staff, a social worker and solicitor will have to be endured by the patient - these are regarded as ordeals by most of them.

Non-detainable patients

Since the introduction of the Mental Capacity Act 2005, the number of assessments that are followed by a decision against compulsory detention is increasing. Patients who are assessed for formal admission but not found to be detainable may develop new risks subsequently as a result of the assessment procedure itself. Before assessment, mental health professionals may place themselves in covert locations around the patient’s house and neighbours may watch eagerly behind their curtains. Thereby the patient’s social image is damaged. After meticulous assessment, it may be a relief for the patient that they are not detained and that euphoria may continue for a short while but all too often damage has been done. The patient who is tormented by psycho-social stressors may find the assessment experience intensifies the injury. The decision about whether it is appropriate to assess someone is therefore an area in which more clarification and some management guidelines are much needed. In situations such as these, untoward incidents have been periodically reported. That may mean that the professionals involved and perhaps also family members who initiated the assessment, blame themselves and endure severe guilt feelings or blame each other. Furthermore, psychiatrists are not mind readers. It is possible that a patient will cleverly deny any suicidal intent during assessment, intending to fulfil a suicidal urge afterwards and that may falsely appear to be a reaction to the assessment. An interview for assessment may be the factor that takes them beyond their limit. Because of all these circumstances, the patient may need intensive home care and counselling after an assessment that does not lead to hospital care. In addition to treating mental illness, it is the duty of the psychiatrist to defend the sanity of patients. The difficulty of defining normalcy is notorious: it is easier to detect psychiatric symptoms than to describe normal behaviour.

Tribunals

Mental health tribunals are demanding and may be humiliating and intimidating. They are highly stressful for the patient and clinician and they involve the breach of patient confidentiality. Tribunals are often emotionally charged scenes for the patient and psychiatrist, they may result in traumatisation. The largely professional make-up of a tribunal is often perceived as intimidating by patients, who tend to be suspicious of collusion between professionals and above all of their reluctance to challenge the decision of a psychiatrist.⁷ Psychiatrists who are aware of legal profession’s ignorance on psychiatric issues dominate the tribunal scene by flamboyant linguistic expressions, while lawyers question the objectivity of psychiatry and the expertise of psychiatrists in legal matters. Tribunals are concerned with the legality of detention and not with the appropriateness of treatment. However, one study has shown that patients who appear before tribunals find it easy to accept they require compulsory admission. ⁸ Psycho-geriatric patients find it extremely distressing to attend tribunals. Hospital managers’ review hearings are often arranged and carried out promptly. Managerial hearings involve local people too which may make them less intimidating for detained patients.

Involuntary treatment

Although mental health staff usually have the best of intentions, when mandatory treatment is applied to patients it may prove traumatic and counter-therapeutic. The experience of undergoing forced treatment adds to the patient’s perception of stigma and discrimination. Involuntary psychiatric drug treatment is bound to be less effective than voluntary treatment. An outcome may be misdiagnosis, long-lasting and disabling side effects. Forced treatment potentially violates a person’s right to respect private life under Article 8 of the European Convention on Human Rights. Article 8 is violated only if patients can prove the treatment given is more harmful than the claimed therapeutic benefits, yet the clinician can administer the treatment if he thinks it is therapeutically necessary. Compulsory treatment makes patients feel infantilised, especially because forced psychiatric treatment often involves coercion, emotional intimidation, bullying and threats.

Community Treatment Order (CTO) is being constantly evaluated in terms of its merits and demerits. The results have been inconclusive and warrant more systematic studies. It was Section 41 of the Mental Health Act that inspired the introduction of CTO - the main purpose being to protect the community from the aggressive behaviour of some of the psychiatric patients as in the case of the successful Section 41. There are indications that CTO has fulfilled such a goal. It was also targeted to enhance compliance and concordance with the mental health services and to prevent suicides but studies indicate that those goals were not achieved.^9,10 The Oxford Community Treatment Order Evaluation Trial (OCTET) substantiates a lack of any evident advantage in dropping relapse.

The “knee jerk” reaction from part of community service has apparently resulted in spontaneous readmissions of patients under CTO. It has also contributed to prolonged detention of patients awaiting community placement under CTO. This is because detained patients must stay on section 3 or 37 to allow the Mental Health Act to be converted to CTO upon discharge. Obviously, such a scenario curtails liberty. Patients always feel bitter about the “hanging feelings” of continued detention. Coercion runs the risk of weakening therapeutic alliance. It may be true that if fewer conditions are imposed, CTO could serve as a “memory knot” for patients with limited insight. Despite all the controversies surrounding the benefits of CTO, its use is increasing worldwide. ¹¹

Assertive Human Rights

All human beings have individual rights and mental health professionals in particular must be mindful of those rights. Table 2 presents the list of assertive human rights, as modified from Gael Lindenfield (2001). ¹²

Table 2, Assertive Human Rights

Discussion

Community care is more innovative than compulsory detention in hospital. For majority of patients, the best way forward is having high quality home treatment facilities as it is least restrictive and using compulsory detention should be the last resort. In some cases, forced psychiatric admission is indicative of failure in the supply of quality home treatment. One thing that sometimes leads to in-patient admission is lack of confidence in the service available. The perception of home treatment may be at fault here - it needs to be understood as more than merely staying outside hospital. Forensic patients and treatment resistant psychotic disorders lacking insight may be a different state of affairs. CTOs have serious impact on the autonomy and privacy interests of individuals and should not be applied to compensate for under-resourced community services.

Caring and supportive relationships between mental health staff and patients during involuntary in-patient care have considerable bearing on the outcome of compulsory detention. A recent study has revealed that among patients who have been detained involuntarily, perceptions of self are related to the relationships with mental health professionals during their inpatient stay. ¹³ Perceived coercion at admission predicts poor engagement with mental health staff in community follows up. When professionals demonstrate their genuineness and encourage patient participation in the treatment options, coercive treatment would be perceived as less of an infringement to the autonomy of patients and their sense of self-value. ¹⁴ If patients maintain both positive and negative views about detention, interventions should be designed to enhance positive experiences by focussing on respect and autonomy.Patients admit only compulsory detention gave them an opportunity to receive medication in a time of crisis and report it did not necessarily prevent thoughts relating to self-harm. It simply reduced the opportunities for impulsive acts.

‘Rooming-in’ is worth debating as an alternative to compulsory detention. This is the voluntary participation of so-called confidants, who may be chosen family members or trusted friends. They provide a 24-hour vigil for the patient in a safe hospital environment. An Australian study has suggested this system is highly valued by nursing staff, patients and their families.¹⁵ It is an initiative that needs further testing and evaluation. The resolution of angry feelings towards the mental health professionals has a significant bearing on their future compliance. The post-detention period tests the attention given to patients by mental health professionals. Here the staff members have to take the initial steps required to repair damaged relationships which may have developed in particular with angry patients. Detained patients should be offered counselling in post-discharge follow-ups and should be given satisfactory explanation of the circumstances for formal admission. Detained patients should be given the support to enable them to: rewrite their life story; reconstruct a sense of self; achieve healing of the assault of their illness and the treatment procedures inflicted on their personality. Specific interventions should be designed and evaluated in order to deal with any unresolved PTSD symptoms relating to formal psychiatric admission.

It seems that psychiatry is gradually losing its allure for future doctors.  All around, one can detect an air of pessimism from colleagues about the creeping 'socialisation' of this important field of medicine. There is no longer the breadth of interest in the subject and each sub-branch, for want of a better expression, has its followers and adherents. Proponents of one particular facet of treatment are zealous in the pursuit of their own interests. Psychotherapy is pitched against the neurobiological, rehabilitation and social psychiatry against the pharmacologists, all trying to mark out their own piece of territory, with some yearning for a place in the history books, or at the very least, an acronym. Some psychiatrists do not believe in diagnoses; others ridicule the concept of personality disorder, autistic spectrum disorder, or drug treatment; some believe psychiatric illness is the fault of governments, and there are probably a few who do not believe in psychiatry at all! 'Research' studies are cherry-picked by all sides to illustrate the ineffectiveness of 'alternative' treatments. The full picture or perspective of ill health is blurred and narrowed by a minority who believe they alone know what is right for patients, and psychiatry is 'intellectualised' by others to give it an air of authority and profundity it does not possess. Morale and training are suffering and, if this state of chaos and insanity continues, the discipline itself will implode and cease to be of interest to anyone, save the warring factions in the profession itself.

Once upon a time it was considered that a reasonably broad mixture of community and hospital services would provide benefit for patients with mental illness. Staff involved in their care, who have the rather cumbersome and oxymoronic description of being called 'mental' health professionals, would also widen their experience because of the continuity of care provided.  It was hoped patients who clearly did not need to be in hospital (for example, waiting for appropriate accommodation) could be discharged. Clinical need would determine those who required further rehabilitation/treatment in hospital, and would not be swayed by pressures, often financial, to discharge. Now, with the setting up of Home Treatment and other teams the situation has ironically worsened, because there is an implicit opinion in this arrangement that hospital admission, even for the seriously ill or indeed violent patients, is the least desirable option and something to avoid at all cost, even when care in the community is not immediately available or adequate. Care provision for the elderly is a separate concern and is not under discussion here.

In the domain of general adult psychiatry those patients who are in need of care, be it medical or social, are languishing at home, desperate for help, being offered assessment after assessment by disparate teams. There are not enough care professionals to cope with the demand. Home Treatment Teams in particular, are under considerable sustained pressure and stress to ensure further reduction in beds. Rehabilitation beds are being closed. 'It is cheaper to keep patients in the community', we are told. Or, if that does not suit, the liberal stance might be, 'What does hospital admission achieve'? That's fine if the problem is not on your doorstep. Psychiatrists who oversee inpatient care are also pressurised to discharge patients as soon as possible, so the very old notion of 'incarceration' (that worn-out cliché from the antipsychiatry lobby) seems facile, to say the least. On the contrary, doctors now have the added worry of prematurely discharging partially treated ('we need the beds') as well as more vulnerable patients who cannot cope. Most patients who take up psychiatric hospital beds do not want to be in hospital in the first place as they often, rightly or wrongly, do not see themselves as ill. Many hospital beds are now occupied by 'Section patients', and conversely, many very ill patients are left to go it alone because they refuse hospital admission and do not want community team involvement, yet are not 'sectionable'. The inference seems to be, 'If not sectionable or under CPA (Care Programme Approach) it is not our concern.'

Where there are sufficient provisions for outpatient care, some of the damage may be mitigated. Overworked staff including community psychiatric nurses (CPNs), support time recovery workers (STRs) and occupational therapists (OTs) often have the thankless task and enormous responsibility of seeing patients at home, some of whom are threatening and potentially dangerous, others erratic with their outpatient clinics attendance not always through deliberate evasion but often the result of the very condition causing the problem, for example, lack of insight. Other patients do not engage either through hostility or loss of motivation induced by the underlying problem, say, drug and alcohol misuse. Chronic patients are not ill enough to be on CPA and diagnostic 'conundrums' are left to others to sort out. With the introduction of the New Ways of Working,¹ the traditional outpatient clinics are being abolished and replaced with community clinics ('short-term' outpatients really). Ideally a community clinic should be run by CPNs as they usually understand the medical, psychiatric, psychological, and social needs of patients. In the authors' opinion the clinics should be Consultant-led because despite the tendency to classify everyone as 'clinicians' many staff feel uncomfortable with this role as it implies or infers a degree of clinical responsibility for which they are not qualified. Psychiatric nurses (especially those with a general nursing background) are ideally placed to carry out this function by virtue of their wide experience; also they are aware when to seek medical help when needed. Often they are more informed about patients than the primary physician or indeed the psychiatrist because of more frequent contact, either via liaison with the hospital wards or through home visits in their role as CPNs.  Nurses and other staff (for example, social workers) are involved in patients' discharge from hospital (usually determined at pre-discharge meetings) and are therefore an essential link in the continuity of patient care before patients are eventually seen in the 'community clinics'. Requests for domiciliary visits from general practitioners (GPs) to physicians themselves have become a thing of the past, with the exception of those psychiatrists working with Home Treatment Teams and Assertive Outreach Teams. Nowadays it is not uncommon for patients to be waiting months on end (more assessments) before being deemed 'appropriate' to see a Consultant Psychiatrist.

Certainly there are patients who do not need to continue seeing a Consultant Psychiatrist for years on end and should be discharged back to the GP to reduce unnecessary costs and to avoid a dependency culture, in the same way a patient with mild arthritis does not need to see a rheumatologist or a patient with anaemia does not always need the expertise of a haematologist, to use simple analogies. However, sometimes GPs are unwilling to reciprocate or feel out of depth with 'psychiatry' that this is not always possible. The chronicity of many psychiatric disorders perhaps harnesses the belief that new treatments may emerge which only a psychiatrist, with his/her specialized knowledge, can implement and deal with. This type of scenario is seen with many other illnesses in all fields of medicine (chronic psoriasis, rheumatoid arthritis, multiple sclerosis) yet no one is suggesting that GPs solely should be left to manage these conditions. It seems the clinical risk to patient care is not thought through and this no doubt will lead to serious repercussions later. In our estimation, physical and mental illnesses are so often intertwined that their management should be equally shared by physicians and psychiatrists.²   

Swings and Roundabouts

Such is the pressure by management (under the thumb of civil servants) and 'those in the know', reverentially referred to as ‘Commissioners’, that health professionals in psychiatry have to defend their clinical judgment and carry out numerous risk assessments (defensive medicine) of patients who are to be discharged from the outpatient clinic back to the GP in any event. Patients may be fortunate enough to receive a few last appointments with the Community Clinic (when they are up and running: some are at the time of writing) before they are shown the door and sent back to the GP, all to save money. Packages of care will not disguise the fact that vulnerable patients are being left to fend for themselves, just as they were in the past when the large  institutions closed down without any forward planning as to how and where patients would survive. Yet ‘management training’ and ‘mandatory courses’ continue inexorably, often provided by 'expert' outside speakers, costing Trusts considerable amounts of hours lost, let alone the  expense, instead of employing more nursing staff to cope with the ever-increasing workload. We are led to believe that reducing 'outpatient numbers' will lead to less pressurised work on staff, which really does not fit. All that will be happening to the extent that 'outpatients' will now be filling to the brim with CPA patients (read 'psychoses') instead of a good case-mix of patients required for general experience and training. It seems to be forgotten that there are patients who feel very unwell and are unable to cope, yet are not suffering from major psychiatric disorders.

The next scenario will be the revolving door ‘GP - Access/Assessment Team - possible Consultant Psychiatrist advice and at most two follow-up appointments (if one is really ill) - Community Clinic - discharge to GP system’, to replace the premature hospital discharge-readmission system which failed miserably in the past. When the patient relapses (or rather, when the illness remains static) the GP refers back into the system and the whole process begins again. In this way the Trusts receive money by reaching their targets (discharging patients) and are paid a second time when GPs 'purchase' more care. Those patients with 'minor problems' (not in their GP's estimation) will whittle away and remain unhappy. 'They can always see a counsellor' is the unspoken passive riposte. Furthermore, there will be less clinical variety for doctors and students, as their work will amount to prescribing 'powerful drugs' (we are told by the antipsychiatrists), monitoring serum lithium (and other drug) levels or checking blood results and clozapine dosages, because the Talking Therapies will be curing all and sundry. If only. We are reverting to the bad old days of pseudomedicine and pseudoscience.

Academicians and those who sit on government advisory bodies with grandiose names would have us believe there are far more effective ways to support people at home, or if they have no home, a crisis house will do. Meaningless, empty statements such as 'randomised controlled trials' (given the complexity of the issues under study) often with some reference to National Institute for Health and Clinical Excellence (NICE) guidelines, are used to support questionable findings. Despite all the 'new ways of working' national stress levels are at their highest because of rising unemployment, unexpected redundancies, increasing debt through credit card borrowing, and suicide rates are going up. New ways of Working is not working and any 'ad hoc survey' (note we did not say 'research') will reveal the depth of disillusionment all professionals in the discipline of psychiatry are experiencing, and not just the hallowed psychiatrists. Rudderless multidisciplinary teams are not the answer: teams require management. The term 'leadership' is becoming redundant (one only has to look at successive governments) and is often merely a spur for making money out of meaningless and time-wasting leadership courses which seem to be sprouting everywhere. Among the many qualities 'leadership' embraces are a sense of humour, assertiveness, fairness, creativity, openness, integrity and dedication, all to be found in one individual; presumably! Hierarchical structures may work, contrary to the sweeping statements of some,³ because people who are experienced in medical, academic and management matters (with perhaps a sense of humour) tend to command respect from team members. It is not enough to be an expert in cognitive behavioural therapy (CBT).

No place like home

How does one establish trust and rapport with patients when there will be less opportunity to do so because their care and progress are determined by market forces?  Instead of decreasing outpatient volume or confining this aspect of care to CPA patients only, outpatient departments should cater for the mounting levels of stress in the community (poverty, debts, redundancies, threatened job losses) through increased staffing levels and training/supervision of more social workers, CPNs and occupational health workers. Where possible such staff should attend as many clinics as possible (not just CPAs) to offer a more holistic approach to patient care. If anything, policy makers, clinicians, managers, carers and user groups need to collaborate and clamour for a more integrative mental health service, not fracture the already fragile set-up.  Community clinics are seen as a stepping stone to discharging from the mental health services (those who set them up don't like this analogy), which in theory is a good idea. The problem lies in the precipitous nature of transfer from outpatient to community clinics. Some very ill patients with chronic conditions are ironically not a burden to the system, in that they do not need to be seen frequently nor do they not require repeated admissions to hospital, yet if left to their own devices and discharged back to Primary Care would soon find life unmanageable as they rely on the expertise of health professionals to remain reasonably stable. Many patients have physical problems, some partly the result of the very treatments given to alleviate their underlying condition (obesity, hypertension, ECG disturbances, Type 2 diabetes and so forth), and need careful monitoring and supervision which is best provided by CPNs and other staff, in the same way a Health Visitor, Practice Nurse, or Diabetes Nurse Specialist might offer his/her expertise to a GP practice.

There will always be patients who need to be seen in the outpatient department with the emotional security and staff support this provides.  We are aware that some 20% of patients miss their mental health appointments but then people miss appointments for other interviews and not always because they are unwell.⁴ Some people miss appointments because they feel better. This is surely not a reason for abandoning the outpatient system, which serves the remainder of the patient population quite well.  We have experienced an unprecedented expression of worry and disappointment by patients who have been told they are not ill enough to be followed up at the outpatient department. Now mental health professionals are also frustrated, because they perceive their remit is to refer back to the GP as swiftly as possible, without having thoroughly assessed a patient over a period of time. First on the target list will be those patients who have not been seen by a psychiatrist for several months (‘We don't see them very often, therefore what is the point?') yet many chronically unwell patients may not want to attend outpatients, or have sufficient insight to realize they need to attend, for reasons outlined above. Will Outreach Teams in every Trust be abandoned to save money? Was it not their role in the first place to help those reluctant to receive treatment? What messages are we giving to patients other than being 'just a number, a hospital statistic’'? Those who have had the ‘luxury’ of a hospital admission usually comprise the very psychotic, and the personality disordered, and of the latter some consider they should not be in hospital anyway. The gains that have been made over the past decade in early intervention and engagement with patients by Assertive Outreach Teams will be lost. Yet, there is a continuing demand from patients and their carers to be seen by doctors.⁵

Here is how the 'new' system works. New Ways of Working, set up some years ago 1  and imposed on us,  was  meant to be an innovative approach to consultants' contracts by encouraging multidisciplinary teamwork ('When did consultants ever not consult their fellow professionals'?), reviewing the continued necessity for outpatient clinics, advocating more scheduled time for carers (colleagues we have spoken to cannot ever recall not seeing relatives or carers!) and more prominent roles for all team members, encouraging further education and training. Unfortunately we have gone to the other extreme and are being bombarded by all sorts of courses to the extent that much time is lost not seeing patients. Team members may and should undertake postgraduate studies. For doctors, continued professional development is mandatory. We are the only profession that requires revalidation every five years. Nothing can substitute for the medical training doctors undergo and it is a shame that the expertise of psychiatrists is diluted and devalued by their current roles as medication gatekeepers. It is a curious state of affairs or perhaps conveniently forgotten that when Trusts or 'Health Care Reformers' talk nowadays about working in teams and 'shared responsibility', the Consultant-led team concept is dismissed. Where there are Consultants who do not feel up to the role of leading a team, or are uncomfortable making assertive decisions and would rather take a back-seat thus avoiding the responsibility of being in charge of a team, then a Specialist Registrar nearing the end of training could fill this position. Multidisciplinary means 'several' not 'equal' disciplines of learning, ideally each discipline contributing a part to the whole. The medical member of the team is nowadays confronted with the added indignity of having his/her patients described in management-speak as customers, consumers, clients, service users, in fact any title that does not describe the ill person as a patient. It also reflects a creeping normalisation of 'political correctness' thrust upon us by the social engineers and should be resisted. We want patients to be treated with respect not as 'service users’, waiting for the next bus or train. Trusts are now seen  to promote a business approach to health care, thereby gaining the approval of their masters, the civil servants and politicians.⁶ Lots of tick boxes and targets, with subtle threats of redundancies or talks about 'natural wastage'. Meanwhile, the College sits idly by.  

Another concern is the training of future psychiatrists which is slip-shod and bureaucratic (lots of forms and assessments). There is hardly any room to accommodate medical students. Junior doctors who practice psychiatry are not receiving the continuity of supervision which existed years ago. The 'junior doctor' is less visible because of European working time directives, on-call commitments with days off in lieu, study leave, annual leave, and the inevitable sick leave. Passing the Member of the Royal College of Psychiatrists (MRCPsych) exams nowadays does not necessarily equate with clinical experience anymore. Even the nomenclature is confusing - not just to doctors and management (‘CT1’, ‘ST1’ and so forth) but also to staff, and reduces the profession to an anomalous set of categories no outsider understands, not to mention the loss of identity it creates in the individual doctor. What was wrong with Senior House Officer (SHO), Registrar, Senior Registrar, and Consultant? Unfortunately, we believe it is now too late to revert this shambles born out of the chaotic modernisation of medical careers. ⁷

The future is bleak and many doctors (and indeed nurses) are becoming disenchanted by psychiatry, feeling let down by a Royal College which seems to accommodate every new social trend rather than concentrating on improving the status of a once fascinating field of medicine. Lots of wake-up calls, but no-one is getting out of bed.⁸ Strange having a 'trade union' that ignores its members! Could someone inform the College that nowadays most General Adult Psychiatrists are almost reduced to measuring lithium levels, advising on clozapine doses, and attending meetings. No wonder the numbers of potential psychiatrists are falling. How would this dilution of responsibility work in a surgical unit? Would the team members decide how an operation is to be carried out because one of them is trained in resuscitation? Contrary to reports³ consultants are not happy with the present set-up, though it is unlikely our Royal College hierarchy will do anything about it. Many psychiatrists nowadays have an extensive academic knowledge of medicine, psychology, sociology, and neuropsychiatry, and no longer want to be minor players in the game, or undermined by a system that encourages power without responsibility.

Fragmentation breeds disinterest

What is the answer?    The previous system, though not perfect, worked well. This had its shortcomings too (oversized catchments areas, Consultants in charge of many wards, and so forth)7 but the continuity of care was there. Patients discharged from hospital were seen by the same team. GPs could refer directly to Consultants (as is the case in other medical specialties) and patients were then seen in the outpatient clinic. However, often the patient would attend such clinics for years because GPs were reluctant to resume care. Nowadays the training and education of GPs is exemplary and most are more than capable and indeed willing, to continue to provide support for their patients provided there is a back-up plan. The academic training of psychiatrists has never been better but their clinical skills are suspect. Therefore there needs to be an overhaul in the examination system as well. Actors are not patients. Simulated psychiatry is not the same as simulated surgery. Simulation is a technique not a technology, we are told. It is not a substitute for doctors examining real patients in real contexts. The same applies to nurses. All nurses (CPNs) could easily be trained to do ECGs, act as phlebotomists, and arrange routine tests. Many already do. Give back to nurses the skills they enjoy in other fields of medicine. For psychiatrists there are numerous courses one can attend to broaden their medical knowledge. Most GPs take an interest in a holistic approach to their patients (social, psychological, physical). As matters stand GPs now refer to a borough 'Access and Allocation Team' with no one held accountable, and even though requested by the GP, a Consultant Psychiatrist's opinion is not always provided. Responsibility is the province of senior doctors and management and should not be diluted by putting pressure on the Team as a whole whose individual experience varies considerably. Doctors (and nursing staff) should have mandatory training in psychological therapies (cognitive and behaviour therapies specifically). A fixed number of sessions in addition to their usual duties could be part of the job plan for those doctors interested in the psychotherapies per se, or put another way, a holistic approach to patient care, which is what most doctors do in any event. Patients would then have the benefit of medical and psychological input simultaneously (let's call it a cognitive-medical model). Waiting lists would be dramatically reduced at a stroke and Trusts would no longer have the responsibility of finding and employing unqualified (in medicine or psychology) 'talking therapists'. People who are generally physically well and who do not have serious psychosocial problems or psychiatric illnesses could receive treatment elsewhere through their GP, counsellors or other psychotherapists (those with no medical or psychology degrees) of their own volition. There is no need to clog up the system with 'customers'. We are not a supermarket!

Complaints will inevitably follow when patient dissatisfaction begins to emerge, which is only a matter of time. More serious incidents will be a consequence of too many bed closures and staff shortages. Dilution of responsibility means that no one person seems to be accountable when things go wrong and patients are left stranded (read the Francis Report ⁹). Already GPs are frustrated by the lack of informal contact with psychiatrists who are once again seen to be retreating to their ivory towers, having been overwhelmed by lots of courses, lots of training, lots of meetings, lots of empty rhetoric. Too much emphasis nowadays is placed on the sociological/psychological aspects of patients' illness and so serious conditions are missed. GPs should be able to refer directly to their colleagues where there are immediate concerns and not have to wait for triage meetings which delay this process. After all, GPs know their patients best. Community clinics could take the bulk of moderate conditions (which are causing undue stress) and see patients for as long as necessary (not a determined number of appointments) before deciding the GP can resume responsibility. 'Packages of Care' and other outdated expressions should be confined to the dustbin. Patients are not fooled by promises of cardboard boxes with little pink ribbons. Continuity of patient care requires a flexible approach which encompasses easy access to information and a direct pathway to services and medical care when needed.

Knowledge in the making

Psychiatrists should concentrate on more difficult and complicated cases (as was the case in the past) as well as routine moderate conditions, enabling them to use their broad skills more efficiently and effectively. Some psychiatrists see too few patients and this should be changed. Perhaps there is a case for psychiatrists rotating through some specialties say, every five years, for example, between Rehabilitation and General Adult Psychiatry. There are many patients who are not on mood stabilisers or clozapine who require intensive input and combined medical expertise and rotating between posts would offer valuable experience. A more varied approach is thus needed but do we really need all those subspecialties? What ever happened to the general psychiatrist with a special interest? In our view at least one year of neurology training should be mandatory for psychiatrists during their training. No formal examinations, just certificates to prove the courses have been completed; otherwise the system grinds to a halt. Under this system a doctor could still theoretically become a consultant after nine years postgraduate training (three years in foundation training and neurology), and six years Psychiatry (to include neurology, psychology and sociology) which is not unreasonable. Equal emphasis on neuromedical, sociological and psychological factors causing health problems would foster a healthier and friendlier relationship between disciplines which deal with mental illness and primary care providers. As it stands, with the fragmented role of general adult psychiatric services and the emphasis on e-learning and internet training for junior doctors (no hands-on clinical experience) we are facing yet another era of overemphasis on social psychiatry (or rather reverting to ancient belief systems) with its 'neutral' politically correct denigrating sound bites (customers, clients, service users). All will be well if we can just sort out the social problems! The simplistic notion that problems will disappear if we do not smoke, drink, take illicit drugs, keep our weight down, and have a home to go to, is the stuff of social engineering by the 'experts in living,' and alas by doctors who have lost touch with medicine.

Doctors need reminding that psychiatry is that branch of medicine that is concerned with the study, treatment, and prevention of mental illness using medical and psychological therapies as well as paying special attention to social hardship and isolation where present. It is not philosophy or social science. It is to medicine what metaphysics is to philosophy. Psychiatrists need to broaden their horizons and take their heads out of the therapy books to witness the advances in neuroscientific techniques and genetic advancements that have already transformed the nature of medicine. To develop their psychological skills they need to take on board that patients want more than drugs to alleviate distress. Therefore practical techniques such as CBT or DBT (dialectical behaviour therapy) will further heighten their expertise as physicians. Many doctors are already familiar with applying CBT and other therapies. However, doctors should also be aware of the limitations of psychotherapies in general, recognizing and acknowledging that such therapies do not always work either and indeed in some instances may be harmful. Psychiatrists should be part of separate Wellbeing Clinics (perhaps one session per week) to becoming better acquainted and proficient again with physical examinations, investigations, routine procedures (ECGs for example) and interpretation of results (not just screen, but to intervene). This overseeing of the physical health of patients is not always possible in a busy outpatient clinic. Many potentially serious conditions would be revealed and information to the GP or tertiary services made known immediately. Psychiatrists are not 'stuck in a medical model' no more than a physician believes all myocardial infarcts are caused by psychosocial factors or life style. But to ignore the medical advances in molecular biology and neuroscientific diagnostic techniques portrays a profound  ignorance of biological psychiatry and is insulting to those scientists who work  tirelessly, often without much recognition, to further our understanding of 'brain disorders'. It is all very well to talk about art, philosophy, social sciences and literature as having a great bearing on our interest in psychiatry and congratulate ourselves as 'lateral thinkers' but an understanding of the philosophy of say, Bertrand Russell or indeed the school of Zen Buddhism, will not eliminate mental disorder. Romantic as it might sound in retrospect, Vincent Van Gogh did not enjoy cutting his ear off, nor did Robert Schumann feel ecstatic when jumping into the Rhine before being carted off to the asylum.

If we do not embrace a holistic view of mental ill-health we risk not only throwing the baby out with the bath water but the bath itself, thereby causing further dissatisfaction and low morale among doctors with an inevitable negative impact on patient care. Psychiatrists are not bemoaning their loss of hegemony - a favourite word and another myth propagated by the antipsychiatry lobby; rather, it is only too obvious to them (as qualified medical doctors) that patients will suffer in the long term by not being referred appropriately to those who have the expertise to recognize and distinguish between human difficulties and illness. There is also a need to re-examine the impact of psychological therapies and not succumb to the popular and naive notion that they are all evidence-based in scientific terms. In the meantime the 'worried well' can indulge themselves with all the peripheral talking therapies and current fads they desire. Likewise, performance management, outcome measures and payment by results have become relentless tick-box exercises creating unnecessary stress among health care professionals (threats of job losses) who 'must meet targets at all costs', all for a slice of the Commissioners' cake. What a way to run a health service! Patients become meaningless statistics in the meantime. No! The wake-up call should be aimed at those who are intent on destroying the good will and values of the very same people they purport to support, through their social engineering and outdated attitudes.

Interest in cross-species transplantation has recently been rekindled¹. This is due to many developments including the shortage of donor organs, advances in transplant medicine, investment in biotechnology research, and the non-availability of more ethically suitable alternatives to human organs. Increasing success rates in allotransplantations (organs from different member of the same species) has increased the demand on donor organs^{1, 2}. Other types of transplantation include autotransplants (a person’s own organs or tissues are used for transplantation) and isotransplants (organs from one person are transplanted into another genetically identical person, like an identical twin). These options are limited in terms of body parts used and numbers.

Good facts inform good ethics. It is therefore obligatory to look into the current research knowledge about xenotransplants (organs from one species to another, for example animal to human) in more detail. The advocates of xenotransplantation argue that it could provide organs “relatively quickly” and hence save more lives.  If animal organs were easily available for transplantation most eligible recipients would receive the transplantation much earlier on in their illness. It is argued that this may decrease distress and suffering. Whilst xenotransplantation may theoretically increase the survival time, it is unclear, however, whether the negative impact on recipients’ quality of life due to long-term immunosuppressant therapy and the risk of zoonotic infections would in fact worsen the overall long-term outcome³. Recent research suggests that xenotransplantation may be associated with the transmission of pig microorganisms including viruses, bacteria, fungi, and parasites. Because of the recipient’s likely immunosuppressed state, infection and pathologic consequences may be more pronounced. Transmission of most microorganisms with the exception of the porcine endogenous retroviruses may be prevented by screening the donor pig and qualified pathogen-free breeding. However, porcine endogenous retroviruses represent a special risk as they are present in the genome of all pigs and infect human cells in vitro. Until now, no porcine endogenous retrovirus transmission was observed in experimental and clinical xenotransplantations as well as in numerous infection experiments⁴. Nevertheless, strategies need to be developed to prevent their transmission to humans. It is equally possible that many eligible recipients may be denied having a trial of xenotransplantation by doctors who believe that there is an unfavourable risk-benefit ratio. The limited long-term data on outcomes of xenotransplants thus renders ethical analysis difficult.

There is some evidence to suggest that the recipients of animal organ donation may develop a different self image with possible consequences for their identity^5,6.  This happens with human organs at times, but may be a more significant problem with animal organs, as the recipient knows that they have been given a non-human organ. Loss of identity jeopardises the core principle of autonomy, which underpins all medical treatment.

The risk of zoonosis to the recipient and to the wider society cannot be accurately estimated⁷. Hence there is a requirement for vigilant post-operative monitoring⁵ with a possibility of engaging article5 and 8 of the European Convention of Human Rights (for England and Wales: Human Rights Act 1998)^†. Article 12 may also be engaged as the recipients may be restricted from having physical relationships, carrying out their routine day to day activities and socialisation. This is because the prevention of possible risk to the wider public from zoonosis may require the recipient to be put under restrictions with regard to their engagement with others. This may include restrictions to go out, which can result into de facto temporary detentions at home. Hence consenting to xeno-transplantation would be “binding and contractual” over a long period of time. The subject may not have the right to withdraw. This is entering into a de facto contract with potential restrictions or even deprivation of human rights. This would restrict the ability to give informed consent even for a well informed patient, as it is difficult to be fully appreciative of future restrictions of one’s liberty.

Autonomous decision making and thus informed consent may also be put at risk by other factors surrounding xenotransplantation. The decision to embark on xenotransplantation may be primarily driven by an instinctual wish to survive due to a lack of other viable alternatives. Patients in these circumstances may have little or no consideration to medium and long-term effects on themselves and society. However, it is the consideration of such long-term consequences that make a truly autonomous decision, and differentiate it from a decision that is purely based on immediate instinct. Whilst the wish to survive is legitimate it is difficult to make decisions free of the pressure to survive when there is a lack of alternatives.

It also brings up an even more important question: Can any person ever consent to a future restriction or deprivation of their liberty or other human rights? Even if there were an option to define acceptable future restrictions it would be likely that patients could still challenge the legality of any such agreements. They could quite reasonably argue that they have agreed to the restrictions under duress because of a lack of viable alternatives to their xeno-transplants.

Xenotransplantation touches questions of utilitarianism (greatest good for the greatest numbers) and public protection². Utilitarianism takes into account the reasonable interests of society in good outcomes, fairness in the distribution of resources, and the prevention of harm to others. The Nuffield council on bio-ethics embraces a utilitarian approach. However, there are limits to the utilitarian argument for xenotransplants. Even if they were widely available, the treatment would be immensely expensive. Production of a pathogen free donor organ would involve rearing animals in strictly controlled environments, subjecting them to rigorous standards of examination and surveillance. The additional costs of developing a sustainable work force to provide transplantation and post-transplant surveillance of the patient and the community would be high.  The insurance providers may not cover expenses of a xenotransplant. Public health care providers may decline to provide this treatment as it may not be recommended by expert groups as cost effective. Xenotransplantation may commence in the developing world where the regulations are lax and the poor can be more easily exploited⁸. Patients who would potentially benefit from xenotransplantation may not be able to afford it due to its cost with serious implications for fairness.

Xenotransplantation also raises other ethical questions in relation to the wider community.  We have seen that consent of an individual to a xenotransplant has significant bearing on the protection of society⁷. Should the members of a community therefore be consulted if there were any xeno-transplantation experiments in their region? The risk is primarily due to the risk of zoonotic infections, the need for surveillance, and possible quarantine of contacts^7,9.  In addition, if health authorities were to fund expensive experimental interventions like xenotransplantation, other routine treatments of greater potential benefits to society may be jeopardised. Society may also have views about particular animals being used as donor animals¹⁰.  For example religions like Islam and Judaism may feel that pigs are ‘ritually unclean’. They may therefore not approve of certain animals to be used for donation, and more worryingly may fail to socially accept recipients with such ‘unclean’ transplants¹¹.

From a deontological perspective (this judges the morality of an action based on the action's adherence to a ruleor principle) some authors assert that animals have rights similar to those considered appropriate for humans^12,13. The protection of animals has legal status in many countries. Consequentialists may view the suffering and death of an animal as acceptable for the betterment of a human patient, as they would judge the morality of an action primarily by its end result. They would argue that potential benefits and improvement in human welfare arising from xenotransplantation may justify the loss of animal life. However, this will never satisfy the animal rights lobby; especially as whilst minimising the risk of acquired infections, the animals have to forgo greater suffering in the form of isolation, monitoring and investigations. Furthermore, genetic modification can have both immediate and long-term negative effects on animals.

In summary, xenotransplantation has significant ethical consequences. On an individual level, there are the questions of pressure to consent that may negate autonomy and the validity of that consent as well as the difficulties that arise when patients are asked to consent to future restrictions of their human rights. On a societal level there are questions of cost and benefit analysis as well as risks from zoonotic infections. In addition, questions of animal rights need to be addressed before any programs are likely to go ahead.

^†Appendix of articles of the Human Rights Act.

• Article 8 of the Human Rights Act 1998 (The right to respect for private and family life, home and correspondence)
• Article 5 (The right to liberty).
• Article 12 (The right to marry and found a family)

A lifetime of happiness! No man alive could bear it: it would be hell on earth

'The following article is another in a series of critical essays examining the current status of Psychiatry in the NHS'

In therapy                                          

Healthcare organisations are a fertile breeding ground for interpersonal conflict and the development of dysfunctional relationships. The supervisory relationship between trainer and trainee is a particular area of concern for junior doctors. Aside from a problem trainee, such conflict can arise from a difficult supervisor, poor communication, personality clashes and power inequalities. This article will come from a trainee’s perspective in emphasising how these factors relate to the difficult supervisor. Recommendations are made for organisations and individuals on how the causes and consequences of this problem can be addressed .

Establishing a medical college is not similar to establishing a science or Arts College and apart from a huge capital requires a huge number of qualified, competent, MCI compliant manpower to produce quality doctors.^1,4,7 Having established a Medical College, maintaining the standards of education to world acceptable levels with a vision to serve poor Indian masses has been a concern of the Indian planning committees. Also, the good name a college attains is due to the accomplishments of its faculty and alumni. In that regard, proper emphasis on the quality of medical education ,inspite of the recent rapid proliferation of private medical colleges, has rightly been the working domain of Medical Councils all over the country and has consumed energies of Medical Council of India over the last forty years. ^{1, 4, 7 ,10,12}

The Medical Council of India (MCI), the regulatory and advisory body on medical education, approves medical curricula and permits medical school existence and allows for recognition of medical degrees issued by various universities. The accreditation process for medical schools focuses largely on the infrastructure and human resources required and little on the process and quality of education or outcomes.¹⁵ The implementation of the recommendations of MCI regarding recognition or de-recognition of a medical college is governed by the Ministry of Health and Family Welfare, whilst individual universities also have variable sets of regulations for their affiliated medical schools. As a result, there is no uniformity in the standard of medical education across the country. At the time of independence there were just 19 medical schools with an output of 1200 doctors.¹⁰ In 1965, there were 86 medical colleges in India with only a few private colleges⁷ The college total increased to 112 by 1980(at a rate of 30%), to 143 in next decade (rate of growth of 28%) and since 1990 over past 18 years the number has increased to 271, an increase of ~90% compared with the figure in 1990.⁷ Today, there are 271 medical colleges out of which about 31,000 medical graduates pass out every year and private sector medical colleges have grown to account for more than half of all medical education institutions in India ¹³

Evidently, medical education system seems to have had an unregulated growth over the last two decades. It has been pointed out that even the prestigious colleges window dress faculty lists or put up names of non-existing academic members in their staff list. ⁵ Most medical college permissions were gifts given out as largesse or patronage to political heavyweights from health ministry.^1,14 Very few have had adequate space, laboratories or hospitals as per MCI norms. They were and remain ill- equipped and inadequately staffed.¹⁰ This unregulated rapid growth in enrolment of medical students and poorly implemented regulations relating to admissions, faculty strength and infrastructure in medical colleges adversely impacts quality of training in Indias medical institutions.

Many reputed physicians and surgeons, professors, directors and deans working in new private medical colleges fabricate and falsify records like even birth records and lie to the MCI and the courts in order to get their medical college of questionable standards approved or recognized. Illegal money is involved in the business of getting new private medical colleges approved or recognized by the MCI and the health ministry. The decay of medical colleges reflects the general trend in this country .^4,5 Corruption and bribery have made permanent inroads into medical education since past few decades in health universities or entrance examinations. Even clerks in the universities leak question papers and manipulate marks. ¹ Perhaps the worst kind of gross unethical practice in academic medicine happens around the time of inspection by the Medical Council of India (MCI) post 1998-2000, in new private medical colleges. In emergency-like frenzied two day shows, busloads of patients are mobilized to fill up empty wards, carloads of doctors are paraded before the inspectors, and even instruments are hired or shifted between colleges, during the period of MCI inspections.⁴

Privatization in general has been known to increase the gap between rich and poor, amounting to encouraging survival of the richest which cannot be a acceptable goal of any civil society.⁸ And, the policy of excessive privatization of medical care delivery system has undermined health services and further limited the access of the underprivileged.^3,8

Privately, many managements agree that it is very difficult to get faculty and that it is even more difficult to retain them in the wake of continuous offers or lure from newly established medical colleges. Certain medical college locations in smaller cities or semi-urban areas do not have facilities, ambience, or charm of big cities hence attracting teachers or other qualified staff to such medical colleges has been difficult, and various inducements have been applied. Such colleges have been surviving council inspections by window dressing or luring faculty with money. In certain new colleges which are literally brick fresh, bereft of hostel or quarters or other amenities the teachers delay even more to move or settle down themselves. At times doubts are established whether an impossible set of conditions and heavy financial burden is imposed on Medical college managements, by the MCI just to make management fail MCI inspections, but at the same time, some stringent MCI regulations have helped faculty of Medical colleges by ensuring job availability.

Doubling of medical colleges over last 15 years has improved the number of medical practitioners in India, but will the mere increased numbers mean a higher quality health care delivery system is debatable. Most management fail to fulfill the excellent set of norms stipulated by Medical Council of India. It is worthwhile, in national interest to note that, we have been loosing medically qualified post graduates to Western countries since till recently Medical College teaching jobs were low paid and did not give that richness or respect attained by private practitioners. After the Karnataka Government & Pondicherry scales new implementation in 2007, with a heavy Non Practicing allowance teaching profession has gained respectability vis--vis elite in society like software engineers. Similar uniform pay scale implementation is need of the hour, all over the country to prevent medical teacher mass migrations.

Nearly 27000 teachers are required as per Ananthakrishnans calculations ⁷ to fill the faculty positions in 270 medical colleges purely for the purpose of teaching MBBS.He ignores the existence of ~300 Diplomate National Board hospitals across India and requirement of faculty for DNB courses. He also ignores MCI recognized institutions exist in other countries like China, Nepal, Malaysia, Netherlands and have been training MBBS doctors of Indian origin. All these institutions have been drawing medical teachers to satisfy MCI or DNB stipulations for accreditation. Hence we have to account loosing faculty to such Institutions. Also his manpower calculations are only for colleges purely teaching MBBS and ignore multiple course Colleges like KMC Mangalore, Manipal which harbor 90 MSc students per year per department and ignores existence of PhD students which evidently will require more teachers. He also ignores the net strain on the same faculty who are simultaneously teaching BPT, MPT, etc in allied institutions. A great academic strain on medical college teachers ,exists,which has never been accounted by MCI nor by Dr Ananthakrishnan.So, on the whole, it means that a great qualified medical teacher shortage exists in India. Either it is due to the excessive number of courses imposed on the same faculty or maybe it is inefficient use of existing qualified medical teachers for non teaching purposes.

Contrary to the opinion of Health ministry, eminent educationists Sood & Adkoli point out that the doctor: population ratio has already exceeded that required by the country and there is mal-distribution of their services. They feel that the menace posed by the growing merchandisation of medical education has to be warded off and efforts should be made to ensure maintenance of standards and check the unplanned growth of substandard medical colleges and substandard education norms in universities or their constituent medical colleges. This mal-distribution of medical manpower is the centered on biased political will and seat purchasing power in the community. With the correction of medical manpower maldisditribution medical standards will harmonize throughout India.^11,12

Indeed, given the sharp increase in the number of medical colleges and the doubling of enrolment capacity after1980s it is difficult to imagine that enough trained full-time faculty exist to adequately staff the newly created colleges or DNB Hospitals and maintain reasonable teacher-student ratios.⁹ Dr Ananthakrishnan proposes to allow MSc from Non Medical Universities to teach Medicine. ⁷ It will be gross medical impropriety to allow such injustice to be allowed by Medical council of India which is supposed to uphold medical education standards across India. What glory does it give Indian medical education system to have a bunch of unqualified non medical doctor MSc teachers seeking to run coaching medical classes a la science tuition centers we fail to see. What is the necessity to increase number of medical college, or medical college seats, in inadequacy of appropriate medical teachers? Is it possible to permit inadequately trained staff to run these colleges, and will the output reflect quality abroad? Emphasis here is not on excellent university results, these MSc teachers, produce by mere mugging up of unconnected facts or figures or excellent power point teaching but what MBBS educated teachers can produce by moulding young doctor student minds by bringing in relevant clinical experience.

Some Solutions

Today, India has the highest number of medical colleges in the world and consequently the highest number of medical teachers. Yet, shortage of medical faculty and lack of medically oriented teaching by appropriately trained MD faculty have tarnished Indian medical glory. The unprecedented institutional growth has created a national quality challenge for medical education and has resulted in varying standards across medical graduates. There is a national need for well-trained faculty who will help improve programs to produce quality graduates. ^5,14 Annual student intake is said to be a critical factor in assessing the requirement for teachers as per Ananthakrishnan,⁷ and should dictate the employment. A punitive MCI, DNB Board and vigilant state medical councils can act synergistically to decrease medical student intake in Medical Institutions where teachers are not ready to go or do not exist. MCI and DNB Board also need to do more for its medical teachers- give them more respect, recognition, arrange for their pensions, gratuity, relieving orders or get involved in pay scale recommendations as no entity exists till date to safeguard medical teacher interests. Measures are required to ensure private medical colleges proper regulation by the medical council. Further, Indian Health ministry has been known to interfere in the functioning of MCI, DCI and DNB Boards, override MCI, DCI and supreme courts decisions and this is undesirable.^12,14,15

Increasing the retirement age of MD teachers up to 70 years will harness hard earned medical experience of senior professors to guide preparation of efficient faculty and will reemploy retired teachers . This will also lead to discipline enforcement, more projects, PhDs and papers of relevance. Else, MCI can think of sharing of medical faculty among medical colleges, or dental colleges, and ensure less burdened teaching schedules. Implementing integrated medical education system-will help, as has been experimented in -KMC Manipal, Sri Ramachandra Medical College. Present paramedical system is a confused network of PhDs who have not enriched Medical education system, a proof of which can be the absence of a single Nobel laureate or international repute medical scientist or of the glory of IISc departments, in 270 odd medical colleges across India, even Manipal, or AIIMS in spite of having the system for 50 years. Merging of homogenous specialities like merging of biochemistry with physiology or pathology, microbiology with pathology, or creation of a discipline of laboratory medicine merging pathology, microbiology and biochemistry has been suggested in yahoo groups like mdbiochemists. Merging of homogenous specialities decreases the requirement of professors in biochemistry and microbiology by providing MCI norm requirements of professors from pathology. Also merging of Anatomy with Surgery will be worthwhile and achieve similar objective of providing deficient staff from Surgery department, who happen to be plenty. It is said to bring about some integrated medical education also. This cure is supposed to provide a broad based intermingling for net objective of efficient medical teaching by qualified professors, peers in interrelated departments. We would further extend their argument in suggesting that the proposed speciality merger need not be complete and final but a temporary arrangement for next 20 years.

Acute shortage of medical teachers needs to be filled. Appropriate solution exists within medical education system itself and help can come from recruitment of medical brethren from clinical sciences to fulfill non clinical department norms, as has been happening successfully ,silently ,without MCI approval ,in Tamilnadu and Andhra pradesh government medical colleges. A whole lot of MD or MS or DNB doctors are ready to serve as Medical teachers, but colleges have never used their teachership as MCI does not permit this. Many such part-time consultants who are practicing in community could deliver excellent teaching assignments and help tide over the so called artificial medical teaching crisis.MCIs generosity to allow MDs of homogenous specialties to teach in Pre or Para clinical sciences for a honoraria, rewards system will effectively ,in a short time solve inadequate improper medical staffing problems forever. Number of seats available in various post-graduate medical courses is approximately 11,005 annually which is one third of MBBS graduates coming out every year. Nearly a third of these seats are diplomas and a diplomate cannot be considered for even a junior lecturer post like an MSc graduate, but will be considered for post of Tutor, the lowest cadre of medical teachership. Thus all DCP (Diploma in Clinical Pathology) and DFM (Diploma in Forensic Medicine) loose out Lecturership to their MD colleagues. Increasing the number of MD seats in Para clinical and preclinical sciences and replacing existing Diploma seats with corresponding MD seats is a just approach and should be the right approach for MCI to follow, since in contrast to before 1960s,in present days no postgraduate seat goes vacant-it means there are no shortage of MD aspirants as wrongly assumed by Dr Ananthakrishnan⁷ .MCI also has to think of giving Junior lecturership posts to MBBS graduates who have been serving as tutors for more than 3 years in any department .

Continuing medical education

Thus there is a strong case for a review of the entire system of medical education and examinations in India. The American style of giving credits for demonstrable good performance throughout the years can be introduced. It will, of course, be necessary to ensure objective evidence of such assessment and performance.^1,8 The Indian Health ministry has realized that efficient medically qualified teachers are in the best position to mould young physician minds hence, Indian National Knowledge Commission (NKC-2008) proposes raising average standards and creating centers of medical excellence, revised medical accreditation; methods of attracting and retaining talented medical faculty members and devising measures to ignite, promote and sustain the research tradition in medical colleges and teaching hospitals.

Medical teacher incentivisation⁸, i.e increments, promotions, paid study leaves will also attract good teachers to stable institutions. In order to recruit good and gifted medical teachers, it is necessary to provide them with regular attractive salaries, amenities and retirement benefits which are realistic and at least on par with the earnings of those in practice.² Emigration of high quality physicians who could potentially serve as medical teachers in local Medical colleges may lead to further declines in the quality of medical graduates produced. To address regional inequities for medical training and related availability of doctors, firstly, it may be useful to set up adequately staffed medical research and training institutions in economically backward areas. Secondly, the government could subsidize the medical education of individuals living in backward areas, perhaps by combining such a subsidy with a bond to serve in the backward areas for a limited number of years. Implementing this bond system will be in the control of the health ministry.

For existing medical teachers, high standards of teaching are to be maintained and improved upon with constant seminars and workshops. Teaching aids, computers, medical CDs, DVDs, medical e-books, Internet facilities and availability of the latest journals and literature on the subject should be provided in every medical college or diploma national board certified hospital.²At the post graduate level, it is the duty of the senior teacher to train the young doctor so that he learns to perform according to accepted international standards.² As a long- term policy, no new medical colleges must be permitted in prosperous states, unless they demonstrate an MCI compliant infrastructure and facilities better than those in existing institutions. A revitalized Medical Council of India must be the only agency permitted to recognize such colleges and health ministry need not have any role.¹ Since advent of the MCI it has been noted that Indian health ministry can not only ignore a negative rating by Medical Council of India, but also openly defy the Supreme Court.¹²

India needs also a MCI controlled and Supreme Court monitored screening system of students admitted to medical colleges under the discretionary management quota so that merit remains the paramount criterion. This requires common entrance examinations to assess student performance across colleges, publicly accessible information on admission standards practiced by colleges, including transparent nondiscriminatory ranking by performance, and enforcement of sanctions on colleges violating norms. A useful first step is the government policy of maintaining a accessible list of recognized colleges, but obviously much more needs to be done to implement ways to increase the supply of MD teaching personnel .Indian policy makers need to think proactively about developing a cadre of doctors focused more on medical education and research. Lastly, the Indian Medical Association, Association of Medical Biochemists of India, All India MD/MS Doctors Association, and other national medical and dental professional bodies must play a greater role to foster true medical and dental education and prevent governmental and political interference.^1,12,14

References

1. Madhok P.Medical tuitions .Issues in Medical Ethics 1997; 5: 23

2. Chinoy R. F: Medical ethics: relationships between doctors.Ind J Med Ethics

3. Qadeer I: The real crisis in medical education. Ind J Med Ethics

4. Chattopadhyay S: Black money in white coats: whither medical ethics? Ind J Med Ethics ;Jan-Mar 2008(1)

5. Bansal P, Supe A. Training of medical teachers in India: Need for change. Indian J Med Sci [serial online] 2007 [cited 2008 Oct 1]; 61:478-84. Available from: http://www.indianjmedsci.org/text.asp?2007/61/8/478/32930

6. Nair KR :Medical college teachers and some ethical issues in Kerala .Ind J Med Ethics

7. Ananthakrishnan N: Acute shortage of teachers in medical colleges: Existing problems and possible solutions.NMJI Jan/Feb 2007: Vol 20, No 1:1-8.

8. Aggarwal A. Strengthening the health care system in India: Is privatization the only answer? Editorial. Indian J Community Med: April 2008; Vol 33; Isuue 2; 69-70.

9. Dutta R. Rash of medical colleges spawns corruption and mediocrity. Express Healthcare Management, August 2002

10. Richards T. Impressions of Medicine in India; Medical education in India-in poor health. British Medical Journal Volume 290; 13 April 1985;1132-34.

11. Sood R & Adkoli BV. Medical Education in India Problems and Prospects. Journal of Indian Academy of Clinical Medicine Vol. 1, No. 3; October-December 2000; 210-12.

12. Mahapatra D .Ramadoss nod to medical college despite SC no-Times of India National edition;29 Sep 2008, 0054 hrs IST, TNN.

13. India to recognize foreign medical degrees :an article published in India Chronicle a monthly e-newsletter Issue No 002;March 2008 http://indianembassy.ru

14. Rajeev D & Mahapatra D Did Ramadoss flout dental council norms?-Times of India National edition;30 Sep 2008, 0449 hrs IST, TNN

15. Sood R. Medical education in India ;Medical Teacher, Volume 30, Issue 6 2008 , pages 585 - 591