Doctor, heal thyself

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Promotions over patients?

Writing somewhere in the late 5th Century BC, Hippocrates (widely regarded as the father of modern medicine) penned down an oath in Ionic Greek. Known, forever after as the Hippocratic Oath, it is a pledge that every doctor takes to practice medicine ethically, honestly, and (most importantly) to never turn away a patient without treatment or advice.

In Pakistan, however, the young doctors who are protesting in the streets, leaving the sick at the mercy of… well, no one… clearly did not take this oath. Or even if they did, they mistook the Hippocratic Oath for ‘Hypocritical oath’ instead.

The facts, in case you haven’t been following, are rather sad: this is the third time, in the recent past, that the young doctors across Punjab have announced a strike and boycotted hospitals. Initially, their contention was to have an increase in their salaries (fair enough). The provincial government, faced with the anguish of the patients (who are their constituents) acceded to the demands of Young Doctors Association (YDA). As a result, whereas the monthly salary of a common BS-17 grade official is Rs 30,000 per months, the salary of a BS-17 grade doctor was increased by 100% to Rs 60,000. While this is not comparable to the salary standards in the West, but for a cash-strapped country this increase was significant (to say the least). And with it, the government and the people, asserted their belief in the importance of the education, talent and service that the doctors render in an ailing society. However, the YDA’s demands did not stop here. This time the protest involves the more esoteric demand of reforming and restructuring the service cadre of government doctors. And having tasted success as a result of their earlier protests, these young doctors seem confident in their belief that if they could just prolong the strike for long enough, causing enough inconvenience (and loss of life) to the patients, the government and the people will have no choice but to surrender to their demands once again.

What a way to hold a gun to society’s head.

To give perspective to this issue, it needs to be understood that doctors in Pakistan can be broadly bifurcated into two categories: government doctors, and private practitioners. While there is some overlap among doctors who are government employees during the day and run their own private practice in the evenings, for the most part, this bifurcation is a useful tool to assess the problem at hand.

With regards to private doctors, the issue is rather straightforward. A person who, having gone through the long and rigorous process of becoming a doctor, may choose to practice medicine in his/her individual capacity, or become associated with a non-governmental clinic or hospital. The equation: patients, out of their own choice, come to see this doctor and the doctor in turn is free charge whatever fee he/she chooses. It is simple demand and supply. There is no cadre of promotions (except the increase in fee), and no structure of the job (except for hard work). This doctor is not out on the streets protesting because it is a waste of time. Every minute that this doctor is not in the clinic is a rupee wasted in real terms.

The problem rests squarely in the sphere of government doctors. These are individuals who (also having gone through the same rigorous process as the private-practice doctors) have chosen to join government service under the ministry of health. Let me reemphasize: chosen to do so! What might be the reasons behind this choice are irrelevant. But as a result of this choice, the government doctor is assigned a bureaucratic grade, gets a government salary irrespective of how many patients he/she treats, is promoted from time to time and retires with a pension. In essence, this doctor wears two hats – a government servant, and a doctor – and therefore has double the responsibility (to the government and to his/her profession). And having been employed a government servant, this doctor is assigned the critical responsibility of treating (poor) patients in rural parts of Pakistan, or in the government hospitals in urban centres (where the poorest of our society go in search of affordable medical treatment).

Sadly, this government doctor has, for a while now, been unhappy with the salary scale and service structure. And to address these grievances, this doctor has decided to take to the streets, leaving the patients at the stretcher in the meanwhile.

From a purely legal perspective, this doctor is in violation of his/her responsibilities as a government employee. Government service entails following all lawful directions of the government. More specifically, to the extent of doctors, nurses, emergency work personnel and law enforcement, The Punjab Essential Services Act, 1958 mandates that these professionals will not “disobey any lawful order given in the course of such employment, or attempt to persuade any person to disobey any such order”. The spectrum of penalties includes dismissal from service, fine, and even imprisonment. Given the fact that these doctors chose to join government service, they cannot be allowed to fall outside the fold of law in terms of their employment.

Perhaps more important, however, is the moral obligation at stake here. The requirements of Hippocratic Oath, even if one has never cared to read it, seep through the medical profession. How can an individual deny saving the life of an elderly woman on a hospital bed, on the pretext that the structure of his/her job should be ‘improved’ before an ounce of morphine is prescribed? Where is a moral argument in contesting the speed of one’s promotion in the job (which is all that is at stake here, since the salaries have already been increased) at the cost of letting a child suffer from pneumonia? And if this the deprecated state of an individual’s morality and compassion, how can such an individual be trusted with a stethoscope or a surgeon’s knife?

The writer is a lawyer based in Lahore. He has a Masters in Constitutional Law from Harvard Law School. He can be reached at: [email protected]


 

9 COMMENTS

  1. Compassion only arises when a doctor is on the line. Coming from a lawyer the line "Perhaps more important, however, is the moral obligation at stake here." is pretty absurd. Asking for a job security is the right of any individual be it a doctor, armed forces personnel, lawyer or a police man. Your post is fact less emotional "old" blabber using the compassion card against the "cream of the nation". Only OPDs are closed not In-patient services, next time do a better job at writing such columns which puts shame to your alma mater Harvard school of law!

    • Just because you are a doctor, and someone criticizes you, doesn't mean that you throw stones at them. Have the moral courage to face criticism. And job security, even if a fundamental right, is not above the fundamental right to LIFE of a patient. It is because of Doctors like you that we are in the state that we are.

      Oh, and also, it is not Harvard school of law. It is Harvard Law School!!

  2. Past precedents of Doctor’s Protests( for those who think that situations like these have never happened outside Pakistan.).

    While there were eight doctors’ strikes during the peak of reform efforts in the 1960s, two of the most prolonged and bitter struggles took place in Canada and Belgium. This comparative analysis of the two strikes highlights the philosophy, motives, and strategies of organised medicine in resisting state-led reform efforts
    The leaders of organised medicine in Canada and Belgium shared a very similar philosophy. Both versions of medical liberalism defended the right of doctors to determine the nature of their relationship with patients, especially their untrammelled right to set their own fees, and attacked more collectivist philosophies that viewed healthcare as a public good and right of citizenship rather than a market service provided by physicians to clients or consumers. Rooted in a nineteenth-century conception of the freedom to contract and a limited state, the tenets of medical liberalism clashed with the more collectivist philosophies propounded by social democratic, democratic (non-revolutionary) socialist, and similar centre–left political movements in the twentieth century.
    (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3066667/?tool=pmcentrez)

    -German hospital doctors strike over pay
    The doctors are demanding a 30% pay rise and better working conditions, with regular hours and paid overtime. Previous strike actions, including a week’s walk-out in August 2005, did not have the desired effect. The negotiations failed because of employers’ stubbornness, said the Marburger Bund.
    Despite delays in treatment, patients’ organisations and individual patients sympathise with the strike. They fear that in the long term health care in German hospitals will come even more under threat because of a severe shortage of doctors, many of whom have gone abroad or left medicine, and because doctors are tired and frustrated. The union says that between 6000 and 10 000 left Germany last year. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC14108

    -French doctors go on strike to demand reintroduction of compulsory out of hours work
    Emergency services at public and university hospitals in France last week began a "general and unlimited" strike, organised by the French Association of Hospital Emergency Doctors. Joined by nurses, administrators, and ambulance drivers, the striking doctors are asking not only for more staff, better working conditions, more beds, and more money but a revamp of France's entire emergency and out-of-hours care system. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC55618

    Ethical dilemmas of the doctors' strike in Israel.
    The authors argue that if a doctor is underpaid and forced to work excessively the quality ofmedical care and ability to act in the best interests ofpatients is adversely affected. To avoid 'the necessity to strike' doctors' salaries and working conditions should be set by independent bodies in those countries where doctors are paid by the State. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC13751

    With salaries on par with those of secretaries, Czech MDs prepare for strike http://www.ncbi.nlm.nih.gov/pmc/articles/PMC12304

    Australian doctors on strike. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC14420

    Cuban Doctors on Strike http://www.ncbi.nlm.nih.gov/pmc/articles/PMC16582

    Italian doctors strike over threat to break up state health service http://www.ncbi.nlm.nih.gov/pmc/articles/PMC40449

    Serbian doctors strike for a 40% pay increase http://www.ncbi.nlm.nih.gov/pmc/articles/PMC11268

    Letter from Sydney: The doctors' strike: the saga continues http://www.ncbi.nlm.nih.gov/pmc/articles/PMC14428

    Is it ethical for doctors to strike?
    If doctors (and others) truly believe it is important for patient care, then they must sometimes have the courage to do things that are unpopular and difficult. If the conditions that doctors work under put patients at risk, then (on balance) they are morally obliged to strike. http://journal.nzma.org.nz/journal/119-1236/2037/

  3. In the end I would like you to please have a look at the charter of demand of YDA & decide for yourself if this protest is uncalled for.

    @PROMOTION
    • It should be time scale
    • All Medical Officer who do their higher diploma / degree be raised to status of Senior Registrar.
    • No SR should be serving in the same position for more than 3 years. All SR be promoted as AP after that.

    @GRADES
    A: The grade allocation to the teaching staff should be according to the recommendations of the higher education commission and universities. This is already applicable there. It is as follows:
    SENIOR REGISTRAR BPS19
    ASSISSTANT PROFESSOR BPS 19 + 5 increments
    ASSOCIATE PROFESSOR BPS 20 PROFESSOR BPS 21
    B: The grade allocation for Specialist cadre should be as follows:
    – Consultant BPS 19
    – Senior Consultant BPS 20
    – Chief Consultant BPS 21

    C: The grade allocation of general cadre should be as follows:
    – MO/ WMO/ REGISTRAR/ ADDITIONAL REGISTRAR/CMO/
    – DMONSTRATOR/DENTAL SURGEON/ASSISTANT
    RADIOLOGIST / ANESTHETICS BPS 18
    – SMO BPS 19
    – APMO BPS 20
    – PMO BPS 21

    @Changing of Cadre
    In teaching and specialist cadre 50% induction should be direct and 50% through promotion

    @ EXTRA WORKS:
    Max duty hours should not be more than 42 hrs/week

    @POST GRADUATION ALLOWANCE:
    All doctors who have passed their post graduation should be given extra allowance of at least Rs 30000.

    @HEAD OF INSTITUTION:
    The selection of head of institution (principal, dean, vice chancellor) should be
    strictly according to the seniority.

    @ CONTRACT REGULARIZATION
    All the contract employees including PRSP should be regularized

    @PAY PROTECTION.
    All the contract employees after regularization should be provided pay protection.

    @HEALTH ENTITELMENT
    All the PGs and HO s and other employees of health department should be provided health entitlement.

    @SECURITY AND SAFETY OF THE WORKING STAFF
    The doctors and the other working staff should be provided security /safety during the duty hours.

    @CME
    A reasonable budget should be provided to the institution for CME.

    @TRAINING COURSES / WORKSHOPS FOR TEACHING STAFF
    All the mandatory training courses / workshops should be sponsored by the government/ institution for trainers and trainees.

    @ATTENDING CONFERENCES
    At least three conferences per years should be compulsory by the teaching staff and these should be sponsored by government.

    @CONVEYANCE FOR ONCALL
    a) For on call people conveyance should be provided for pick and drop of the consultants.

    @DOCTOR TO PATIENT RATIO
    There should be a standardized doctor to patient ratio

    @RECRUITMENT
    1. Recruitment of all doctors on permanent basis through the authority proposed by the Government. (SSB / PPSC or any body / board approved by Government).
    2. Till the recruitment of doctors by approved board, the principal / board of management should be given authority to appoint doctors on adhoc / contract basis. Moreover the power of extension should also be given to the principal / board of management.
    3. Doctors working on adhoc or contract basis must be given all the allowances of that post like anesthesia allowance, hard area allowance etc.
    4. Further announcement of seats should be institution specific. They should be bound to serve the institution & will not be transferred to any other place for period mentioned above in this document at para no. 6 except, if they are promoted by the department or recruited to a higher post by recruitment authority and due to unavailability of post, cannot be adjusted in same institution.
    5. After completion of training all PGRs should be offered adhoc MO appointment.

  4. So we just have to save lives? Where is the fact of 100% increase in the basic salary? 60,000 prove it right as the YDA has said, they will call off the strike. Just to quote from a Punjab Govt ad. and not investigating means he actually went to Harvard school of law and not Harvard Law School or may be havaldar school of law! The doctors were made to call the strike as they have face 23 committees after committees without any fruit. A basic salary of a BS 17 doctor or even BS 18 is not 60,000. Blatant false! Just cause they treat patients it does not mean you can take them for a ride or do their media trial with false accusations. Being a lawyer, this guy should have investigated before putting his case. If he goes in court with this "garbage of facts" he will be thrown out! Yes we are doctors, we have studied hard and worked 36 hrs on a stretch. When you all were watching indian flicks we were studying not to get paid less just cause we took the "Hippocratic" oath. Do not be so hypocrite in your analysis or conclusions!

  5. If the "young " doctors are not happy with the salary structure they should just resign. Nobody is forcing them to work for the Govt?

  6. I haven’t read more biased article/ads in so long and this is what saddens me the most. I understand the frustration and anger that is directed towards the medical professional for staging this protest by closing non-emergency Outdoor Patient Departments(OPDs) and more so after reading/watching false ‘factual’ propaganda on TV/Print Media by PML-N. It’s probably very hard to digest, but we don’t love putting people in misery either. We are also part of the same community and would really appreciate if you could spare a few valuable moments and consider for a minute that may be, just maybe there is some weight to the cause and mode of the outburst that is being seen on Doctor’s part.
    Doctors who deal with the most difficult of patients, such as patients who cannot communicate, who cannot act in their own best interests, who live in hopeless poverty, the homeless, and those who stubbornly resist taking responsibility for prevention have the patience of doctors when it comes to their desire to successfully treat and lead their patients to good, or at least better, health."
    This is not to say that the people from other professions work any less or that they don’t deserve any better. Two wrongs don’t make a right and I think we should quit the culture of settling for unjust and unfair workplace structure and environment. More people die from spurious medicine, scarce emergency and non-emergency resources and poor Operation Room conditions then from shutting down of non-emergency Outdoor Patient Departments(OPD) that the YDA has done.
    Please also remember that this step of shutting down Outpatient Departments was not the first line of action. It started off as a "black ribbon " protest and progressed slowly into posters, banners and public march protest. When all these modes of protests failed to wake or even shake our toothless leaders, only then the modes of the protest were changed. Every step that was taken was pre-empted with a notifications to government and a proper protocol was followed. So if you want to blame anyone for the selfishness and cruelty towards patients, guide your guns towards Punjab government instead of professionals who have been serving as literally free, white collared labor for you and your countrymen.

  7. Intensively looking, a job security can never be neglected in any regard. More or less, morality is a matter of person-hood which is not appreciated until a person is payed enough and is content with all he has.
    He can never value a life that way.

    (Subjective opinion)

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