Tuesday 8 December 2015

EM or Critical Care, EM & Critical Care, EM-Critical Care, Critical Emergency Care or Emergency Critical Care- What’s the Right Choice for a Real World Emergency Physician in India ?

From the Desk of Sagar Galwankar, MBBS, DNB, FACEE (INDIA), MPH, Diplomat. ABEM (USA), FRCP (UK)

In my recent conversations with young residents who have graduated with an MD in Emergency Medicine and others who hold various kinds of Non Accredited MD in EM, Certificates, Rogue Masters in Emergency Medicine or Pseudo Diploma’s in Emergency Medicine I have come to realize the harsh truth about what these young trained physicians visualize themselves or rather where they are in today’s era.

We must accept the fact, that in India the majority of jobs for physicians lie in the private sector. When it comes to Emergency Medicine, Hospital Based Practice is the natural course for the career of an Emergency Physician.

Keeping this economic opportunity alive is the best a system can do to keep a specialty alive.

There was a time that Dermatology was the last choice for majority of graduating young physicians and today thanks to the economic growth of cosmetology and aesthetic medicine, Dermatology has suddenly become the top field of choice for new graduates.

There was a time Emergency Medicine departments were called Casualty Departments. This was in 1996 when I first saw the vision for Emergency Medicine and sowed the seeds for its development in India. Today Emergency Medicine boats of having many Father’s but these fathers were nowhere when I started my journey to bring EM to India. “Success has many fathers failure has none”

Anyways, when I started to convince the hospitals to start EM back in 1996, I was mocked and called the “Messiah of Worthless CMOs (Casualty Medical officers).”  It has been a long journey and today every private hospital tries to canvas and market its Emergency Services. The rise of healthcare and the demand and the brand of EM has gone up.

I question whether the economics has become equally lucrative or not for the job market. I will defend the later. Rogue Certifications and Diploma’s and the modus operandi run by many organizations to conduct non accredited courses across private hospital emergency departments led by one or two pseudo leaders (who don’t have any experience at education) has defeated the theory of categorical evolution of a specialty. Today these Non-accredited Programs are run by a Head of EM (who is also mostly having a non-accredited degree) and this head recruits up to 15 students per year by misguiding them that “One Day Their Certificate/ Masters will be recognized”. The students who join these courses haven’t made it to conventional MD/DNB programs nor have they decided to take the International Pathways to USA/UK. They pursue these Non-accredited programs as an option which will add a Few Letters after their MBBS. It would be nice if these letters had UK or USA with them. Whether these Letters really are recognized oversees or not is another story…because what do the patients realize anyways?

So here we are …..We have started these mass training programs across the network of biggest employer for EM … the corporate hospitals. These students generate high fees and income from an erstwhile Casualty now called an ED and also cost way less because it is now operated by a Ring Master called a “Head”. The “Head” Safe Guards his existence by showing this Operandi as a way of productivity for the hospitals.

I have previously discussed how holding conferences or awarding oneself also helps preserve this “Mirage of Image” for these leaders towards the employers and the young physicians who they want to mislead.

What Happens to these graduates once they gets their Diplomas, Masters Etc. The job market is congested with leaders/ Heads or will soon get congested with these pseudo courses. This is because the so called EM Leaders have fed an easier money making option to the employers.  There are no jobs and if there are any, they are low paying like even less than 1,00,000 per month with an expectation that in return for the title of the “Head” you are expected to run the the Operandi of Training which is become a Norm across the Private Hospitals in India.
It’s a vicious Cycle.

You do what you are taught and what you learn, you learn wrong, you do wrong. The people who do wrong believe that they are right and that’s why they do it !


Well India needs Nephrologists, Cardiologists too. Why don’t we pick up all MD Medicine Doctors who know how to do Dialysis and give them a DM/DNB in Nephrology and so also all those who practice Diabetology a DM/DNB in Endocrinology. This cannot happen as every specialty has to evolve and that too with the evolution of healthcare services. By giving a viable option of cheap labor money generating non accredited training program to the largest employer of the specialty of EM, the growth of EM and the academic advantage to Emergency Physicians is gone with the wind.

So what are the options?

Critical Care is the only one which is viable.

Today Critical Care has been able to safe guard the job & Salary economics for its constituents, thanks to the structured growth of this specialty in India. CCM and its structured growth is in a way one of the deterrents to growth of EM because all that is expected from the EP is wheel the patient to critical care. The hospital makes more money if patient lies critical in the critical care unit rather than be stabilized in the ED.

This has given rise to idea that Emergency Physicians can handle critical care or rather emergency physicians are critical care physicians anyways. These students are made to believe that they are getting an Post Graduation in Critical Care with a Title of  EM.

Critical Care is a vast, labor intensive, high knowledge specialty which needs intense training. When you go to a CCM Meeting you realize the different sub specialties in CCM from Neuro to post-surgical critical care, trauma critical care, toxicology critical care  etc.

In India Specialties like anesthesia, chest medicine and internal medicine have made inroads into CCM. Physicians who have training in CCM even today work hard to gain knowledge and very few boast that they know all the sub specialties in CCM well.  

I have heard EM Leaders make callous statements like “what do critical care guys do ?” “Just give inotropes, antibiotics and monitor outputs from GI GU and feed via NG Tube/Peg Tube”

This is wrong and a total disregard for a specialty which is so crucial to healthcare.  CCM Experts do much more and definitely know tons more than emergency physicians. EM Physicians are expected to be trained in handling all emergencies. In India they are definitely not trained in Peads EM.  They can arrogantly boast and lie to themselves and others but fact is they are not trained…that’s the truth. When these misguiding leaders continue to misguide these young physicians that CCM is  EM and EM & CCM are one specialty….. I would call upon CCM Specialist to be cautious. There may be chance that Rogue Mafia will now invade CCM Centers with a Cheap Labor Hiring Operandi like they have done in EM.

 There is a big myth being floated to start EICU (Emergency ICU) so that money can be generated by labelling an area in ED and calling it an ICU. I have confirmed news that these model has started.

I would call upon CCM to safe guard its specialty by cracking down on these rogues. There are many failed Intensivists who have found home in Emergency Medicine. Their hospitals have given them leadership positions to head their Casualties where they too run the Training Operandi.

They need industry support to run these marketing campaigns like Conferences and Award Syndicate. The money is in Critical Care, so guess what……start floating the idea that EM and CCM is one…start training programs to match this myth and encourage graduates to work in CC Units and make CCM their future. Even conferences on EM in India now have partnerships and sessions on Critical Care…. A step to infiltrate a Structured Specialty.

In all these mess……We forgot why we were here…, we were here to provide EM Care to our patients, we started this specialty when CCM was already in existence and now we are coming a full circle to say EM is same as CCM. Yes Emergency Physicians can undergo more training (up to 3 Years) to gain adequate knowledge to staff a CCM Unit but to lead a CCM Unit it will be years. CCM is vast and a lot needs to be learnt. It is the same way Now days Heads of EM are appointed as soon as they confirm that they can operate the modus operandi ….and they always know CCM is there to back them up…

I urge my fellow interested youngsters to question all those who offer to guide them, check their credentials, ask around, talk to different people, explore whether you will have a good job career, don’t get emotional, you have worked too hard to be misguided by a few who are there because their job Is to generate cheap labor and safe guard their positions……

I want all who read my blog to understand that speaking the truth, hearing the truth and accepting the truth is better than to live in a False Reality....there will always be an explanation and a perspective.... the fact is ... is that perspective REAL ?

I believe in the truth and if its the truth.... its Real...I do not deter but I just speak it out !

The future is better when the present is good….and when it involves many then a few cannot reap its fruits…and if few are reaping its fruits …… many are not getting and will not be getting what they deserve……..That’s oppression by false motivation….

Till then the patient continues to seek Emergency Care……..expecting the best,  trusting what is being handed out…..well there is always Critical Care to back the ED anyways !