Welcome to the jungle
Take it day by day
Be ready to get hurt
It's the price you pay
I completed our MBBS only a while ago. I could be a resident, I might have completed my post-graduation, or I might be working as a senior resident. Whatever my original status, these days I am a COVID resident.
The recent violence against the medical staff at the SMHS hospital is heartbreaking especially against the background of the current pandemic. I know that the public do not attack us in Kashmir only. I read an article in USA Today. It tells us that more than half of emergency room personnel were victims of physical violence. They are shoved, kicked at, sometimes spat on, and one in four reportedly assaulted more than 20 times over the past three years. The survey went on further to state that this violence was actually increasing over the period of time. I also read an Editorial published in Lancet which reported that doctor–patient relationships in China were in crisis. Doctors had been injured or even killed by patients at work.
Intolerance and grouse against doctors is a global phenomenon but the developing part seems to lead the world in violence against doctors with 8-38% healthcare workers suffering physical violence at some point in their career. I often talk to retired doctors and they tell me that the average patient/ attendant is more educated these days. Paradoxically, they say, he is more prone to violence. I often ask them why that is so. The wise ones tell me that:
1. They hate trappings of power or control. They have an antipathy towards, and poor image of, medical profession, because doctors are perceived as having control/power over them/their loved ones. This, they are unable to accept.
2. They also have less fear/faith of law (which again is perceived as power or control).
3. They are more knowledgeable; access information easily as a result of information revolution. Like all non-nuanced information, opinions are easily formed.
4. They are more likely to resort to issue-based and temporary organization (even if they don't understand the issue) – mobocracy or anarchy.
5. They often desire to achieve leadership position on an issue without thinking it through.
Accordingly, a minuscule part of the public takes it too far, almost behaving like health sector terrorists in the process.
Everyone says that there has been some erosion in the esteem of physicians and doctors but others reiterate that medical profession still remains a very prestigious profession. What is beyond doubt, though, is that over the years there has been a significant erosion in the stature of medical professionals. Given failing infrastructure, lack of resources, time crunch, overload, stress and pressure from the administration, first line doctors, in my opinion, do a commendable job. What has gone wrong then? Have some doctors been callous? Are the families of some of the deceased unreasonable? Or are we simply calling attention to our plight? I find that there are several flash points in our interaction with the patients.
1.Misunderstandings – miscommunication at any level from explanation of etiology, disease explanation, need for investigations and treatment options.
2. Mishappenings– when the disease course and prognosis are not properly communicated to the patient, if a mishap occurs the treating doctor and staff may be perceived as callous or inconsiderate.
3. Dissatisfaction and Disagreement with physician on modalities, option and course of treatment.
4. Malpractice or suspicion of malpractice about the doctor.
5. Casual opinion – criticism by other/2nd opinion doctor [professional jousting].
We also face a problem of rapid technological advances in the practice of medicine, which, have led to an exponential increase in the amount of information and skills that need to be acquired. Broadly it is a question of dropping vestigial knowledge and re-prioritization of education according to the requirement of the day. The second problem is the alienation of the prospective physician from the society. Perhaps the most alarming problem is lack of empathy, rather a steady decline in its level over the course of medical school.
No one prepares us for addressing the most common complaints and problems like
1. Prolonged waiting times: delay in attention or admission of sick patients or perceived delay in investigation and treatment.
2. Perceived lack of availability of doctor (senior doctor)
3. Perceived lack of care felt by the patient.
4. Altered states of attendants due to severe anxiety or stress
5. Problems of public hospitals: dysfunctional equipment, poor quantity and quality of paramedical and supportive staff (and doctors being at apex have to take blame for it).
But all these points are relevant to a non COVID world. I thought the pandemic would bridge these inherent schisms. It is quite clear that all doctors, especially the junior doctors, are putting their lives on the line each time they enter the ward. I have the same routine worries that most people have. I earn much less than people think I do. The fruit seller at the corner near SMHS might be making more. I worry about taking the virus home. I have parents and I might have a spouse, and very small children. I grapple with the question; My patient or My parent? It is a profound question which has no answers and involves daily soul searching. I am also confronted with a medical infodemic which causes a lot of distress. My guidelines change daily. The advisors vary too. From Mr Trump to the WHO, everyone seems to have an opinion on the COVID. But basically, I do not have any wonder cure to offer. All optimistic studies show marginal benefits. Despite a lot of work, no algorithm is available, at least, yet. The vaccines seem to have got politicised. I worry, about my career which has stalled. My studies, my research and my training have all been taken hostage by the corona virus. I feel that nature has thrown at me a curveball. I am human, I too get scared. But I persevere not because the administration asks me to do so but because I want to help. Ethics dictate that my duty to the patient is paramount only until my own health is at risk. But I disregard this moral argument for a more altruistic one.
However, I sense that the patients understand our relative helplessness more these days. They are not looking at me as a god but as a fallible human challenged by nature unlike anything in the recent past. They seem to be willing to wait it out and assess the grim battle with stoicism. There are other concerns like bathrooms, linen, soap, toothpaste etc. Most of the requests are about nitty gritty. Initially, I used to think that my PPE made me distant and aloof. Now I realize that even though they do not see me, but they look forward to the rounds by the figures in white. One patient even told me that a figure in white is better than no figure at all. They are worried, like me, about a stunning lack of medical leadership. The huge vacuum is difficult to fathom. Despite the fact that they cannot see my smile, grimace or cry, I have felt an unseen connection. A COVID patient understands my isolation because of his own isolation.
As the number of patients with severe COVID sickness increases, and the deaths mount, the tenuous understanding is getting strained. The old mistrust is back. But there is one thing that all the people who point fingers at doctors should keep in mind. If the hospital environment is exposed to violence its practitioners might start practicing defensive medicine, focusing on saving their own skin rather than treating a patient. This could be an unfortunate consequence of attacks on health care workers. We are in this together. There is no room for finger wagging. I am worried about my patients, I am worried about myself, and I am worried about my family.
As a resident on the frontline I must quote that poem
I lied and said I was busy
I was busy; but not in a way
Most people understand
I was busy taking deeper breaths
I was busy silencing irrational thoughts
I was busy calming a racing heart
I was busy telling myself I am okay