Malpractice isn’t merely a wrong diagnosis or faulty treatments, it’s a wide term and inclusive of every abuse, misuse, and dereliction.
It was at 5 am when Maira was awoken by Zain. She sensed right away that something was frightfully wrong. Zain, pressing his stomach, was breathless and groaning with pain. She had never seen her husband in such a condition. He was an extremely patient and uncomplaining person. “I’ve tried everything I could but the pain keeps on increasing. I think we need to go to a hospital”, was all he could say before he sat on the floor and threw up. It had been 3 hours since he was bearing that pain.
Instantaneously, she told herself not to panic, splashed her face to be able to drive, grabbed the available cash, and drove off to a renowned hospital in the posh area of Gulberg. She thanked God while finding a spot to park her car. The person in charge of the smallest ever parking lot declared that he was to keep the car key. Upon demanding a token, M was told that the token guy would be available after 9 am. Z’s terrible condition restricted her from further argument though she was pretty stern about such things.
With a remarkably languid body language, the doctor in the emergency room was not at all in the mood to handle any emergency. The vibes displayed that patients were merely a nuisance in his peaceful duty hours. However, after a few repetitive questions, he made the nurse write a long list of injections, needles, and medical accessories. Meanwhile, Z started throwing up again, and M, who was running out to buy the prescribed long list, was stopped and told by the nurse to hold the pan for Z while he vomited. Poor thing was miserable with pain. M’s mind was poking at her simultaneously: with all the possible reasons for his pain, going out and buying the medicines for him while being somehow concurrently present by his side, also worrying about the kids whom they’d left sleeping in beds, and were supposed to be getting ready by now for the school.
There are questions about the availability and quality of services, discipline, and proficiency of doctors, as well as the standards of emergency services; but the most raised question is about the treatment versus the cost.
It’s a known fact that people confront trust issues when it comes to hospitals and doctors as they’re both assumed to be a party to their vested interests. A hospital rarely takes notice of a doctor’s malpractice or negligence. They’re openly collaborating for economic gains, rather than benefitting the patients. The picture is as imperfect as it seems even if the corporate scenario and the roles of the consumer and vendor are taken into account. There are questions about the availability and quality of services, discipline, and proficiency of doctors, as well as the standards of emergency services; but the most raised question is about the treatment versus the cost.
The healthcare business in Pakistan is one of the most profitable ones. According to the figures, declared by the healthcare resource guide Pakistan, “the National health infrastructure comprises 1279 hospitals, 5527 BHUs, 747 Maternity & Child Health Centers, and 1400 TB centers.” Clearly, the Pakistani government has failed to establish enough healthcare facilities to cater to the variable needs of a huge population. Especially in rural areas, one can’t find a good hospital within a realistic radius.
Based on a publication from JPMA (Journal of the Pakistan Medical Association), healthcare systems worldwide, including both developed nations and developing countries like Pakistan, grapple with the issue of medical errors. Within this context, medical malpractice, also referred to as professional negligence, emerges when a healthcare provider deviates from the expected standard of care within the medical community, resulting in harm or even the loss of life for the patient. This deviation can occur due to either an act or omission on the part of the provider. The term “clinical negligence” is employed to describe the unlawful conduct of a medical doctor or consultant. Pakistan has witnessed several cases related to medical negligence. With the media playing a major role in highlighting and exposing, many incidents have been reported within the last few years. Some alarming instances include: leaving gauze and instruments in the abdomen during surgery, harming the newborn by mishandling and incompetence, using faulty operation techniques, administering wrong injections, using expired drugs, wrong diagnosis and treatment, ending up in injuriously and even death, in many cases.
In Punjab, the implementation of the Punjab Healthcare Commission Act 2010, and in Sindh, the enforcement of the Sindh Healthcare Commission Act 2013, aim to address instances of medical negligence within their respective provinces. The Pakistan Penal Code 1860, specifically Sections 300, 304 (a), 318, and 321, provides provisions for remedies and punishments related to such cases. It is important to note that under the Constitution of Pakistan 1973, no individual, including doctors, is granted absolute immunity.
The age-old adage of ignorance being bliss no longer holds true. It is the collective responsibility of every Pakistani citizen to proactively raise awareness and ensure the proper reporting of incidents involving medical negligence. Several factors contribute to this issue, including the quality of medical education, the need for comprehensive training for all healthcare personnel, the absence of professional ethics, doctors concurrently serving at multiple hospitals while maintaining private practices, inadequate health policies, non-compliance with professional regulations, and the general lack of awareness among the population at large.
The absence of an infallible and reliable law enforcement is the root cause of the monopoly of the healthcare industry and the distrust among people.
Doctors are under oath but so are our national presidents, prime ministers and all the other people in significant positions, playing substantial roles. Hence, oath taking is an otiose ritual in our country. Usually, the cases connected to the malpractice and negligence of hospitals, doctors, and healthcare sector are adjudicated under the consumer, torts or criminal laws. It’s a game of millions to start an infirmary. A layman commonly believes that owners and stakeholders have bounteous reserves and enough friends in the right places to save their necks. The absence of an infallible and reliable law enforcement is the root cause of the monopoly of the healthcare industry and the distrust among people.
Ahsan Aziz, an educationist, and a law graduate, suggests, “An easily understandable, unambiguous, standardized legal contract between the doctor and the patient needs to be implemented, along with a legal undertaking on the part of hospitals to safeguard the rights of patients and to do the best suited, in every case. In case of an infringement, the contract should serve as the evidence to lodge an FIR. Hospitals should also put the basic rules and laws in black and white on the premises. Knowing the rights and doing the duty is significant. Such basic contracts shall create an awareness and act as a caution for both the patients and the hospital.” Prevalently offered is the hospital-based agreement that ensures that the hospital is not to be blamed for anything, not held answerable in any condition; colloquially said to be signing the death warrant of your loved ones.
“It is perplexing why there’s never a consensus among the diagnosis and treatment recommended by the medical doctors. One would direct right while the other would instruct left!” says Anila Nasir. Two doctors rarely come up with the same diagnosis. The patient is always confused as to whom to follow. Some call it just a matter of fame and the name of the doctor. Even with a lot of technology in lab tests and numerous internal scans, the doctors are never on the same page. Psychologically, a health practitioner’s attention also works as a placebo for successful treatment. If the patient does not feel heard and checked up thoroughly after paying a handsome amount, he remains dissatisfied and doubtful about his diagnosis. It happens in the case of almost everyone though the elderly gets affected in a huge ratio. Traditionally, people in earlier times used to have family doctors. All through their lives, they preferred going to the same doctor who had known them and their medical history for a long time. Not anymore! Patients visit various specialized doctors yet; they are not truly satisfied with anyone.
“Doctors lack the general grooming. They’re supposed to be disciplined, punctual, thorough and polite.”
Malpractice isn’t merely a wrong diagnosis or faulty treatments. It is a term inclusive of every abuse, misuse, and dereliction. Rasheed Chohan, a retired officer shares his observations, “Doctors lack the general grooming. They’re supposed to be disciplined, punctual, thorough and polite. I wonder why it’s become a trend: to show unprofessionalism by giving an appointment of 6pm but seeing the patient at 7pm, trying to intimidate and rush, acting like a whirlwind instead of being graceful and kind. Under the banner of noble profession, they take undue advantage of someone already in pain.”
Doctors have their tantrums, remarks Hooria Butt, “The doctor didn’t want to wait much. It was my first delivery, and it was to take a few hours in a normal delivery process. She said she had a flight in the evening and preferred to perform a cesarean section. The doctors have no ethics now. Money is the only professionalism for them.” Saamya Mushtaq, a banker, says, “You’ll hardly hear about normal vaginal deliveries these days. It’s been a typical practice among Gynecologists that they’ll forge a complication and tell you to opt for a cesarean section. They won’t leave us with any choice of opinion. The picture they’ll portray would be that if you won’t survive otherwise. Everyone knows about it. Many women have been a victim of such malpractice. Isn’t it against the oath they take? Isn’t it malpractice? Yes, it is, but nobody can do anything, not even lawyers. These doctors have surpassed all limits of being insensitive!”
Anaya Babar shared another disturbing experience, “Right after the birth, my daughter was taken for the cleaning process, as it usually happens. The untrained nurses of the nursery wounded her mouth from the inside while cleaning. They probably had long nails, or the tools they used were mishandled. When my baby girl came to me, after an hour, she spitted blood. It was alarming for us. The doctors took her away and without asking or informing us, started injecting antibiotics to a newborn baby. Her first food wasn’t milk but a strong antibiotic. It caused her jaundice. I had almost lost her due to their negligence, but there were no checks and balances to make them answerable. The hospital didn’t take any responsibility. Nobody paid heed.”
The unending expectations and demands of the lower staff are a nuisance for the admitted patients and their families. Sadia Mazhar commented, “The lower staff constantly acts like beggars. The hospital management silently supports them and they blatantly ask for extra remuneration for the services which they’re given salaries for.” Shahbaz Masih, a worker in a hospital in DHA, Lahore declares, “Yes, I do demand extra perks and cash from the patients and their attendants. Every sweeper, cleaner, janitor, and custodian expects that. We clean their shit and vomit and what do we get? Just a few grands! Our salaries don’t match the kind of work we do. Doctors charge lakhs for an hour’s surgery, and PKR 3500 for a five-minute check-up. Hospitals charge thousands for a room. The patients pay them because they’re rich, we deserve an incentive, too. Hospitals usually don’t accept but they do allow us to demand ‘bakhshish’ and ‘chaye paani’, and if someone gives happily, nobody shouldn’t have a right to object.” Aaya Perveen in the maternity ward says, “It’s a culture now. If people would stop giving, we won’t expect it. Instead of criticizing us, there should be serious steps taken to increase our basic salaries.”
Hospitals are not a happy place for anyone. Instead of providing some comfort and assistance, hospital staff does not leave a single chance to mint money. “My wife got food poisoning, and I took her to a well-known hospital in Gulberg, Lahore. The doctor wanted to keep her admitted overnight. Since there was no separate female ward, the hospital offered private rooms. The smallest room, the cheapest, was for PKR 28,000 per night. It had a bed for the patient and a chair for the attendant. I could have booked a bigger room in a luxurious hotel for the same price!” says Mr. Wasif Haider.
If you know someone influential, the treatment is way different. Mr. Bilal Malik shared, “My father had chest pain and fell in the bathroom three years ago. He was unconscious. We rushed to the hospital’s emergency room. The doctor on duty suspected that it was a heart attack. Before they would attend to my dad, there came another patient with bodyguards, seemingly, son of someone in power. He had just a 100-degree fever! The whole hospital went crazy in attending him, leaving my dad half dead on the stretcher.”
Labor room is a torture cell for the women. Women have all sorts of terrifying stories, to the extent of being criminal. “The nurse stole my gold rings and earrings while I was under anesthesia’s effect. On gaining senses, I complained with the doctor in charge but responded with anger and denial. The hospital refused to accept any allegation or hold anyone accountable for my loss. Instead, they said that I had some hallucinations; I was under post-partum depression and making things up. They went to the extent of prescribing some anti-depressants.” states Naila Junaid.
Another anomaly is about prescribing medications. The doctors prescribe the medicines of the pharmaceutical companies with which they have an alliance. Asim Anwar, an experienced medical representative and pharmacist states, “The companies offer incentives to the doctors with the consideration that they’ll prescribe their medicines.” Patients have to buy the same even if alternative options are available. As the representatives of such companies, our commissions align with the ratio of convincing the doctors.”
While the legal rights bestowed upon patients bear undeniable significance, it is of parallel importance to enlighten them about their inherent responsibilities. There are instances where attendants and patients behave inappropriately. Dr. Saleh Awan articulates, “Doctors usually enjoy a certain esteem and deference, which may be because people think doctors are differently educated, or qualified to save lives. Yet, there are people who reject the criteria and make it a business transaction. They treat us as a service provider charging them for the time and service. To be honest, we do work for money but there’s still a line, a fine line, which has to be maintained between the doctors and the rest of the service providers.” Nida Hassan, a young doctor shared, “Doctors work at the front-line in pandemics and emergencies. We obviously get paid, still it’s not all about money. Being a junior doctor, I’ve worked 16 hours straight during the covid-19. There were no leaves, our lives were at risk, yet we didn’t hesitate. In return, if we expect an extra fraction of respect, I think it’s justified.”
Saif Gardezi comments, “The brutality of nurses has no bounds. They inject and behave like butchers. We call them ‘sister’ though they do not deserve because they are ill-mannered and arrogant. You would not find a competent, soft spoken and kind healthcare worker in Pakistani hospitals.” Nosheen Gill, a nurse in the emergency room of a famous hospital in Lahore shared her views, “There is a huge difference in the standards of education, privileges and salaries of the nurses in other parts of the world. If you compare with the West, you’ll know the reason behind the stark difference of service quality.”
These are just a few surfacing dilemmas related to practices, services, and ethics. Healthcare remains an area where in-depth, policy-oriented research and judicious reforms are required. Pakistan, as a peripheral state, faces countless challenges. In order to address the issues and improve, the prime focus should ideally be at the grass root levels. Since public services are insufficient, the private sector needs to be regulated. The nonavailability of health insurance and lack of reimbursement plans in the employment sector worsens the situation. Legitimization of a code of conduct, standardization of services and the charges might prove to be a rational start. However, awareness is one thing that will mobilize the masses, not just to enhance the knowledge of their rights but also, to acknowledge their duties.
