Covid-19 ward care in most Indian hospitals, including Dr. Ram Manohar Lohia Hospital in New Delhi, has been triaged into levels of care. The initial contact upon admission is in a triage ward, from where needy patients get transferred to the SARI ward that deals with respiratory infections, and then, after confirmation by an RT PCR test, the patient is moved into Covid care wards. The serious cases are handled in the ICU by specialists trained in this field.
It is obvious that these different levels of care require different levels of specialists, and a mere MBBS graduate or medical intern may not suffice at all levels. Before addressing how we can garner more support from MBBS graduates in Covid care, the existing manpower distribution needs to be understood first.
Hospital workforce during Covid
The basic principle is to first ascertain whether the hospital is also treating non-Covid cases. Most, if not all Delhi government hospitals, have shut down non-Covid functions, which in my view is incorrect because there are other diseases that require care and cannot be adequately handled online. As most central government hospitals take care of both Covid and non-Covid cases, the doctors are divided into two sections. In a purely Covid hospital, the staff crunch may not be so dire as all doctors are available for Covid care. Doctors are divided into seniors and juniors. The seniors constitute permanent faculty and the juniors comprise post-graduates (PG), senior residents (SR), interns, and junior residents (JR). There has been a presumption that interns and junior resident doctors will all come and work in droves during Covid, but this is unlikely.
Among senior doctors, those who are above the age of 60-62 have comorbidities and are not usually posted in Covid care. The basic premise of increasing the retirement age to 65 was to cater to the ‘paucity’ in teaching faculty in medical colleges. By now, with the new liberal ‘equated’ rules, they are actually in excess, thus the premise has outlived its utility. Nevertheless, we do not see the above-62 faculty in active Covid care.
The junior faculty and doctors have been on Covid and non-Covid duty for the last one year. The PGs, specifically, have been through it multiple times, and a large number of them have even been exposed to the virus. In PG training, every doctor relies on the belief that a junior will come and take over the work. The third-year PGs in some hospitals, like the RML hospital in Delhi, are being kept for non-Covid duties to save them from the stress of pandemic duties. So, essentially, the actual junior workforce in Covid wards comprises first-year and second-year PG students. The SR cohort is a dynamic pool and cannot be increased overnight, because there aren’t enough third-year PGs to apply for it for obvious reasons.
How to fulfil shortages
The NEET PG is a well-conducted online examination that caters to over 20,000 PG seats. The plethora of coaching institutes and the money involved is stupendous, and the students would not risk a medical issue just before their exams. To expect them to waste their preparation by taking on the risks involved in Covid duty is difficult to digest. Some of them are also called “library doctors”, hence the chance of them offering themselves up seems even more unlikely.
If these students had already taken the exam and were allotted hospitals, I am sure they would have volunteered for Covid duty. This would have injected a dedicated pool of young doctors into hospitals at this time, and given a large number of PG students some mental and physical rest. Admittedly, that still leaves a large number of MBBS graduates who either may have not prepared for the exams, may not pass it this year, or who would presumably work even without any postponement of exams, but we do not see a line of such hopeful candidates outside our hospital to join duty.
Now, coming to the second level, the specialists. These are doctors who have at least 5-6 years of experience in their field and join via UPSC examinations or state interview boards. Such interviews do take time, but ad hoc interviews can be done without much ado. One needs these fresh faculty to give a breather to the specialist doctors who have been at it for a year. Most hospital administrators do not involve super senior faculty in Covid work for multiple reasons, so, that pool of experience is wasted.
Therefore, if by some divine intervention, India’s two lakh MBBS graduates decide to forget the time and money spent on the numerous coaching institutes that promise them a rank – and join at the salaries promised – they can at best help in the triage and some Covid wards. We will still need a specialised pool of doctors to handle and supervise the core areas, which probably has been missed by all except us who are at the front line.
The way forward
Before the medical community faces further fatigue, here are some solutions on how we can support its workforce:
1. Hold the NEET exam at the earliest, declare the results, and ask all successful candidates to mandatorily join the Covid workforce, pending allotment. Assured of a seat, they would definitely chip into the current Covid care efforts.
2. Expedite ad hoc specialist interviews for faculty posts.
3. Third-year PG students will need to give their exam in any form and can be then put on Covid care duty to tide over the crisis as they are the most adequately trained at present.
4. The central government has the power to reverse and alter any decision in the interest of the nation. Faculty who are above 62 years of age must be excused from Covid care duty, and the inexplicable logic of extending retirement age needs to be reevaluated.
Lastly, there is a need to keep our ears to the ground and listen to those on the front lines, and not just armchair experts. As Bernard Baruch said, “Millions saw the apple fall, but Newton was the one who asked why.” Hopefully, we all will ask “why” before it’s too late.
The author is a professor of dermatology at RML Hospital, New Delhi. Views are personal.