The Making of a New Medical Specialty: A Policy Analysis of the Development of Emergency Medicine in India

Document Type : Original Article

Authors

1 Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA

2 Health Systems Program, Department of International Health and International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

3 Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

Abstract

Background
Medical specialization is an understudied, yet growing aspect of health systems in low- and middleincome countries (LMICs). In India, medical specialization is incrementally, yet significantly, modifying service delivery, workforce distribution, and financing. However, scarce evidence exists in India and other LMICs regarding how medical specialties evolve and are regulated, and how these processes might impact the health system. The trajectory of emergency medicine appears to encapsulate broader trends in medical specialization in India – international exchange and engagement, the formation of professional associations, and a lengthy regulatory process with the Medical Council of India. Using an analysis of political priority setting, our objective was to explore the emergence and recognition of emergency medicine as a medical specialty in India, from the early 1990s to 2015.

 
Methods
We used a qualitative case study methodology, drawing on the Shiffman and Smith framework. We conducted 87 in-depth interviews, reviewing 122 documents, and observing six meetings and conferences. We used a modified version of the ‘Framework’ approach in our analysis.

 
Results
Momentum around emergency medicine as a viable solution to weak systems of emergency care in India gained traction in the 1990s. Public and private sector stakeholders, often working through transnational professional medical associations, actively pursued recognition from Medical Council of India. Despite fragmentation within the network, stakeholders shared similar beliefs regarding the need for specialty recognition, and were ultimately achieved this objective. However, fragmentation in the network made coalescing around a broader policy agenda for emergency medicine challenging, eventually contributing to an uncertain long-term pathway. Finally, due to the complexities of the regulatory system, stakeholders promoted multiple forms of training programs, expanding the workforce of emergency physicians, but with limited coordination and standardization.

 
Conclusion
The ideational centrality of postgraduate medical education, a challenging national governance system, and fragmentation within the transnational stakeholder network characterized the development of emergency medicine in India. As medical specialization continues to shape and influence health systems globally, research on the evolution of new medical specialties in LMICs can enhance our understanding of the connections between specialization, health systems, and equity.

Keywords

Main Subjects


  1. World Health Organization. The World Health Report 2008 - primary Health Care (Now More Than Ever). Geneva, Switzerland: World Health Organization; 2008.
  2. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923-1958. doi:10.1016/s0140-6736(10)61854-5
  3. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. doi:10.1111/j.1468-0009.2005.00409.x
  4. Weisz G. Divide and Conquer: A Comparative History of Medical Specialization. New York, NY: Oxford University Press; 2003.
  5. Dohler M. Comparing national patterns of medical specialization: a contribution to the theory of professions. Soc Sci Inf. 1993;32(2):185-231. doi:10.1177/053901893032002002
  6. Leeming W. Professionalization theory, medical specialists and the concept of “national patterns of specialization”. Soc Sci Inf. 2001;40(3):455-485. doi:10.1177/053901801040003005
  7. Bucher R, Strauss A. Professions in Process. Am J Sociol. 1961;66(4):325-334. doi:10.1086/222898
  8. Halpern SA. American Pediatrics: The Social Dynamics of Professionalism, 1880-1980. Berkeley: University of California Press; 1988.
  9. Stevens R. American Medicine and the Public Interest: A History of Specialization. 2nd ed. Berkeley, CA: University of California Press; 1971.
  10. Rosen G. The Specialization of Medicine with Particular Reference to Ophthalmology. New York, NY: Froben Press; 1944.
  11. Zink BJ. Anyone, Anything, Anytime: A History of Emergency Medicine. Philadelphia: Mosby; 2006.
  12. Nigenda G, Solorzano A. Doctors and corporatist politics: the case of the Mexican medical profession. J Health Polit Policy Law. 1997;22(1):73-99.
  13. Jeffery R. Allopathic medicine in India: a case of deprofessionalization? Soc Sci Med. 1977;11(10):561-573.
  14. Sood R. The leadership crisis of medical profession in India: Ongoing impact on the health system. J Family Med Prim Care. 2015;4(3):474. doi:10.4103/2249-4863.161366
  15. Zachariah A. Tertiary Healthcare within a Universal System. Econ Polit Wkly. 2012;47(12):39-45.
  16. Baru RV. Privatisation of Health Care in India: A Comparative Analysis of Orissa, Karnataka and Maharashtra States. New Delhi, India: Indian Institute of Public Administration; 2006.
  17. Mahapatra P, Upadhyaya S, Surendra G. Primary or specialist medical care: Which is more equitable? A policy brief. Natl Med J India. 2017;30(2):93-96.
  18. Subhan I, Jain A. Emergency care in India: the building blocks. Int J Emerg Med. 2010;3(4):207-211. doi:10.1007/s12245-010-0223-7
  19. Rajagopal MR. We have a Responsibility. Indian J Palliat Care. 2016;22(3):239-243. doi:10.4103/0973-1075.185025
  20. David SS, Vasnaik M, T VR. Emergency medicine in India: why are we unable to ‘walk the talk’? Emerg Med Australas. 2007;19(4):289-295. doi:10.1111/j.1742-6723.2007.00985.x
  21. Rajagopal MR. The current status of palliative care in India. Cancer Control. http://www.cancercontrol.info/wp-content/uploads/2015/07/57-62-MR-Rajagopal-.pdf.  Published2015.
  22. riram V, Baru R, Bennett S. 2018. Regulating recognition and training for new medical specialities in India: the case of emergency medicine. Health Policy Plan. Forthcoming.
  23. Arora P, Bhavnani A, Kole T, Curry C. Academic emergency medicine in India and international collaboration. Emerg Med Australas. 2013;25(4):294-296. doi:10.1111/1742-6723.12110
  24. Mascarenhas A. Doctor pushes course on infectious diseases. Indian Express. 2011.
  25. Zachariah A. Discrimination in Health Care and the Structure of Medical Knowledge. New Delhi, India: Medico Friends Circle; 2014.
  26. Pothiawala S, Anantharaman V. Academic emergency medicine in India. Emerg Med Australas. 2013;25(4):359-364. doi:10.1111/1742-6723.12095
  27. Aggarwal P, Galwankar S, Kalra OP, Bhalla A, Bhoi S, Sundarakumar S. The 2014 Academic College of Emergency Experts in India’s Education Development Committee (EDC) White Paper on establishing an academic department of Emergency Medicine in India - Guidelines for Staffing, Infrastructure, Resources, Curriculum and Training. J Emerg Trauma Shock. 2014;7(3):196-208. doi:10.4103/0974-2700.136866
  28. Shiffman J, Smith S. Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet. 2007;370(9595):1370-1379.  doi:10.1016/s0140-6736(07)61579-7
  29. Shawar YR, Shiffman J. Generation of global political priority for early childhood development: the challenges of framing and governance. Lancet. 2017;389(10064):119-124. doi:10.1016/s0140-6736(16)31574-4
  30. Shawar YR, Shiffman J, Spiegel DA. Generation of political priority for global surgery: a qualitative policy analysis. Lancet Glob Health. 2015;3(8):e487-e495. doi:10.1016/s2214-109x(15)00098-4
  31. Benzian H, Hobdell M, Holmgren C, et al. Political priority of global oral health: an analysis of reasons for international neglect. Int Dent J. 2011;61(3):124-130. doi:10.1111/j.1875-595X.2011.00028.x
  32. Prata N, Summer A. Assessing political priority for reproductive health in Ethiopia. Reprod Health Matters. 2015;23(46):158-168. doi:10.1016/j.rhm.2015.11.004
  33. Walt G, Gilson L. Can frameworks inform knowledge about health policy processes? Reviewing health policy papers on agenda setting and testing them against a specific priority-setting framework. Health Policy Plan. 2014;29 Suppl 3:iii6-22. doi:10.1093/heapol/czu081
  34. Smith SL, Neupane S. Factors in health initiative success: learning from Nepal’s newborn survival initiative. Soc Sci Med. 2011;72(4):568-575. doi:10.1016/j.socscimed.2010.11.022
  35. Shiffman J. A social explanation for the rise and fall of global health issues. Bull World Health Organ. 2009;87(8):608-613.
  36. Rhodes RAW, Marsh D. New directions in the study of policy networks. Eur J Polit Res. 1992;21(1-2):181-205. doi:10.1111/j.1475-6765.1992.tb00294.x
  37. Dalglish SL, George A, Shearer JC, Bennett S. Epistemic communities in global health and the development of child survival policy: a case study of iCCM. Health Policy Plan. 2015;30 Suppl 2:ii12-ii25. doi:10.1093/heapol/czv043
  38. Cohen MD, March JG, Olsen JP. A Garbage Can Model of Organizational Choice. Adm Sci Q. 1972;17(1):1-25. doi:10.2307/2392088
  39. Yin RK. Case Study Research: Design and Methods. 5th ed. Thousands Oaks, CA: SAGE Publications, Inc; 2014.
  40. Patton MQ. Qualitative Evaluation and Research Methods. Beverly Hills, CA: Sage; 1990.
  41. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117. doi:10.1186/1471-2288-13-117
  42. Charmaz K. Constructing Grounded Theory: A Practical Guide through Qualitative Analysis. 1st ed. Thousand Oaks, CA: Sage Publications; 2006.
  43. Miles MB, Huberman AM, Saldana J. Qualitative Data Analysis: A Methods Sourcebook. 3rd ed. Sage Publications, Inc; 2014.
  44. Gilson L, Hanson K, Sheikh K, Agyepong IA, Ssengooba F, Bennett S. Building the field of health policy and systems research: social science matters. PLoS Med. 2011;8(8):e1001079. doi:10.1371/journal.pmed.1001079
  45. Crotty M. Introduction - The Research Process. In: The Foundations of Social Research: Meaning and Perspective in the Research Process. Thousand Oaks, CA: Sage Publications; 1998.
  46. Khaleej Times. Trauma deaths can be prevented with emergency care. Khaleej Times. October 17,2014. https://www.khaleejtimes.com/lifestyle/health-fitness/trauma-deaths-can-be-prevented-with-emergency-care
  47. Association For Trauma Care of India. 1981-2011: The way ahead. Mumbai, India; 2011.
  48. Das S, Desai R. Milestones of EM/EMS in India. EMS, India; 2011.
  49. All-India Institute of Medical Sciences. Note for the Academic Committee (To Consider the Question for Establishment of the Department of Emergency Medicine and Creation of Posts of Faculty at the AIIMS New Delhi). New Delhi, India: All-India Institute of Medical Sciences; 1992.
  50. Deccan Chronicle. Apollo to start advanced emergency medicare centre. Deccan Chronicle. September 27, 1993.
  51. Alagappan K, Cherukuri K, Narang V, Kwiatkowski T, Rajagopalan A. Early development of emergency medicine in Chennai (Madras), India. Ann Emerg Med. 1998;32(5):604-608.
  52. Bagchi A. Metamorphosis of Health Care: The Transformation of ‘Private’ to ‘Corporate’ Health Care in Post 1947 India. Proceedings of the Indian History Congress.2010;71:1223-1232.
  53. Deloitte. Sustainable Strategies for a Healthy India: Imperatives for Consolidating the Healthcare Management Ecosystem. Deloitte and All India Management Association; 2013.
  54. Yadavar S. Attention please. The Week. 2014.
  55. Subba SH, Binu VS, Kotian MS, et al. Future specialization interests among medical students in southern India. Natl Med J India. 2012;25(4):226-229.
  56. Das S, Desai R. Emergence of EMS in India. JEMS. 2017;42(4):55-61.
  57. Rimmer A. Indian doctors are recruited to fill emergency medicine gaps. BMJ. 2014;348. doi:10.1136/bmj.g3000
  58. Express News Service. Apollo to introduce diploma course for ambulance staff. Indian Express. September 27, 1993.
  59. First International Emergency Medicine and Disaster Preparedness Conference; October 25-27, 2002, Hyderabad, India. Conference Brochure. North Shore-LIJ Health System, Apollo Hospitals, Society of Emergency Medicine, India.
  60. National Conference in Emergency Medicine, Chennai, India. November 16-18, 2007. Sri Ramachandra Medical College, Society of Emergency Medicine, India, North Shore-Long Island Jewish Health System. Conference Brochure.
  61. Second International Emergency Medicine And Disaster Preparedness Conference. New Delhi, India. November 17-19, 2006. Conference Brochure. Fortis Hospital,  North Shore- Long Island Jewish Health System, American College of Emergency Physicians, Society of Emergency Medicine, India, American Academy for Emergency Medicine in India.
  62. INDUS-EM. 12th INDUSEM General Assembly 2016. Paper presented at: Annual Conference of the Indo-US Emergency and Trauma Collaborative; 2016; Bengaluru, Karnataka, India.
  63. Rajalakshmi TK. A cloud over the MCI. Frontline. 2002;18(26). https://www.frontline.in/static/html/fl1826/18261110.htm
  64. Medical Council of India. Postgraduate Medical Education Committee Meeting Minutes - 16th-17th September 2002. New Delhi, India: Medical Council of India; 2002.
  65. International Emergency Medicine Special Interest Group. Recognition of EM in India. Newsletter of the International Emergency Medicine Special Interest Group of ACEM. 2008;4(1). https://acem.org.au/getmedia/2b307b36-079c-461d-846f-2fab71fa707f/IEMSIG_Newsletter_08-April.aspx.
  66. Medical Council of India. Postgraduate Medical Education Committee Meeting Minutes - 6th June 2007. New Delhi, India: Medical Council of India; 2007.
  67. Government of India. The Gazette of India, Part 3, Section 4. New Delhi, India: Government of India; 2009.
  68. Press Trust of India. MCI President Ketan Desai arrested on graft charges. India Today 2010. https://www.indiatoday.in/latest-headlines/story/mci-president-ketan-desai-arrested-on-graft-charges-72503-2010-04-23
  69. Indian Medical Association, Maharashtra State. eNewsletter May 2010. Mumbai, Maharahstra, India; 2010.  http://imamaharashtrastate.org/wp-content/uploads/2010/05/IMAMS_eNEWS_LETTER_MAY_2010.pdf.
  70. Federation of Emergency Physicians India. AELS (Accident & Emergency Life Support). http://www.epi.co.in/aels/.   Published 2014.
  71. National Accreditation Board for Hospitals and Healthcare Providers. Information Brochure for Certification of Emergency Department in Hospital. New Delhi, India: National Accreditation Board for Hospitals and Healthcare Providers; 2016.
  72. The Hindu. Emergency medical care courses in all medical colleges. The Hindu. January 9, 2012. http://www.thehindu.com/todays-paper/tp-national/emergency-medical-care-courses-in-all-medical-colleges/article2786425.ece
  73. International Conference on Emergency Medical Service Systems, New Delhi, India, All India Institute of Medical Sciences, Department of Hospital Administration; February 9-11, 2012.
  74. American Heart Association and American Association of Physicians of Indian Origin. Memorandum of Understanding. May 2014.
  75. 75.   Nagarajan R. Illegal ‘PG degrees’ plague emergency medicine. Times of India. 2017.
  76. INDUSEM Health & Medicine Collaborative. INDUSEM2015 Ends on a High Note! 2015; http://www.indusem.org/indusem2015-ends-on-a-high-note/
  77. Times of India. Country needs emergency medical services law: Experts. Times of India. May 4, 2015.
  78. Hoe C, Rodriguez DC, Üzümcüoğlu Y, Hyder AA. “Quitting like a Turk:” How political priority developed for tobacco control in Turkey. Soc Sci Med. 2016;165:36-45. doi:10.1016/j.socscimed.2016.07.027
  79. Parliament of India. Department-Related Parliamentary Standing Committee on Health and Family Welfare. 92nd Report on the Functioning of the Medical Council of India. New Delhi: Rajya Sabha Secretariat; 2016. http://www.academics-india.com/Parl_Panel_report_on_MCI.pdf.
  80. Bloom G, Henson S, Peters DH. Innovation in regulation of rapidly changing health markets. Global Health. 2014;10:53. doi:10.1186/1744-8603-10-53
  81. Levitt P. Social remittances: migration driven local-level forms of cultural diffusion. Int Migr Rev. 1998;32(4):926-948. doi:10.2307/2547666
  82. Mishra S, Trikamji B, Singh S, Singh P, Nair R. Historical perspective of Indian neurology. Ann Indian Acad Neurol. 2013;16(4):467-477. doi:10.4103/0972-2327.120422
  83. Agarwala R. Tapping the Indian Diaspora for Indian Development. In: Portes A, Fernández-Kelly P, eds. The State and the Grassroots: Immigrant Transnational Organizations in Four Continents. Berghahn Books; 2015.
  84. Sheikh K, Josyula LK, Zhang X, Bigdeli M, Ahmed SM. Governing the mixed health workforce: learning from Asian experiences. BMJ Glob Health. 2017;2(2):e000267. doi:10.1136/bmjgh-2016-000267
Volume 7, Issue 11
November 2018
Pages 993-1006
  • Receive Date: 14 September 2017
  • Revise Date: 08 June 2018
  • Accept Date: 10 June 2018
  • First Publish Date: 01 November 2018