By Dr Sanjana Dhungana-Dulal and Hari Bansha Dulal
Society entrusts doctors with the burden of understanding and dealing with illness, but every now and then we come across news where a doctor is intimidated and in some cases assaulted by an unruly mob. Doctors are manhandled and their clinics vandalized. What follows the intimidation is an idea of fair trial. It gets floated for a while in the media. At the end of the day, nothing happens to the perpetrators. The perpetrators never get apprehended and punished.
The time has come to pull the curtain back and get a clear view of what causes medical mistakes to occur. Medical mishaps can be broadly categorized in four areas: physician stressors like the lack of sleep; patient characteristics and complexity; process of care factors such as job overload; and physician characteristics such as experience and exposure. These problems are related to the system and are inherently system problems warranting system solutions. It is not only the doctors that are responsible for the mistakes. In most cases medical mistakes occur because of multiple system failures and involves a number of individuals.
In the United States, the estimated total number of iatrogenic deaths (ie, deaths induced inadvertently by a physician and surgeon or by medical treatment or diagnostic procedure) annually is almost 800, 000. If we compare this number to the deaths caused by heart disease and cancer, it becomes evident that iatrogenic deaths surpass the number of deaths due to heart disease and cancer in America. Compared to 783,936 iatrogenic deaths, only 699,697 and 553,251 Americans died of heart disease and cancer in 2001.
Despite the availability of cutting edge medical technology and well trained doctors the American medical system is itself the leading cause of injury and death. Medical mistake is the 8th leading cause of death in the United States. All doctors, however, experienced and conscientious they may be, make mistakes at some point during their career. Like any other human being, doctors too are susceptible to error. It is a downside of being human.
When it comes to dealing with medical mistakes, we should come up with a more rational way of dealing with the problem, and try to move beyond a punitive mind-set. The punitive mind-set of the general public is the biggest obstacle to acknowledging mistakes by doctors and health care professionals.
Intimidation and physical harm towards doctors will prove counterproductive in the long run because if you punish doctors for making errors, they will never acknowledge any error and out of fear will never try to correct it.
Several studies carried out in the United States have demonstrated that when there is a punitive environment, more than 95 percent of errors do not get reported. Thus, harming doctors does more harm than good. If we are really serious about the safety of a patient, we need to know what is going on with the patient, and we are not going to find out what is going on if we intimidate or harm doctors.
According to Dr Lucian L Leape, a prominent health policy analyst at Harvard Medical School, "the two cornerstones of safety are, one, creating an environment where it's safe for people to talk about their errors and, two, leadership".
Doctors are ethically bound to tell their patients that they have made a mistake and patients have the right to know what is being done to them. However, the question here is: Will doctors be more forthcoming in acknowledging and correcting their mistakes if they are intimidated and harmed?
Like many developing countries, Nepal has difficulty attracting doctors to serve in remote areas. The distribution of doctors is skewed in favor of urban areas. Many district headquarters in hilly areas lack doctors due to which health and wellbeing of citizens living in such areas are being severely compromised.
Initially, like many policymakers in many developing countries, policymakers in Nepal too embraced a notion that the best way to get doctors to go to rural areas was to overproduce them. This notion has failed miserably. What policymakers in developing countries including Nepal failed to factor into the equation is the global labor market. The health workforce is strongly linked to global labor markets. Shortages in health care professionals in developed countries send strong market signals to poorer countries.
In poor countries such as Nepal the pay is low and working conditions are not so encouraging. When the doctors are quite often intimidated, an inevitable response would be to migrate towards greener pasture. Instability and insecurity does propel exodus of doctors and healthcare professionals.
It is estimated that there are more than 21, 000 doctors from Nigeria in the United States and more Sierra Leonean doctors are said to be living in Chicago than in all of Sierra Leone.
The flight of the creative class has begun. The number of Nepali doctors in developed countries such as the United States, England, and Australia is increasing rapidly. Every year the cream of the crop chooses to migrate, rather than stay home and face the lack of educational opportunities, career advancement, and on top of it intimidation.
Out of the many reasons why doctors choose to move towards greener pasture is because they refuse to practice in second-class health systems. Many think it is ethically incorrect to practice in unsafe conditions, where they cannot meet the needs of their patients.
If they decide to stay put and practice in second-class health systems, there is a big probability that some day they will be the victim of intimidation and humiliation at the hands of an unruly mob. Slowly but surely public misgivings continue to rise.Medicine is a noble profession; there is no doubt about that. However, doctors are human beings too with craving for a better life and a secure future for themselves and their family. When politicians cannot devise a policy that guarantees security and incentives, they should not expect doctors to stay and serve the rural poor about whom they care least anyway.