Placement of blame has to be top-down, not down – further down
Far too often, complaints are directed towards the lowest rungs of the workforce, because they are the ones easiest to prosecute.
In the wake of scandal involving a government hospital, the Chief Minister of Punjab is expected to put on his slippers, grab a handful of doctors, nurses, and hospital administrators by their blue collars, and toss them out of the front door to the angry masses to pounce on.
But who are these doctors, nurses, ayas, and administrators? I have never seen their names on a plaque when the facility is inaugurated, nor have I seen their faces on a poster when a development plan is put into action. I’ve only seen Shahbaz Sharif’s glorious visage on such posters – possibly next to Nawaz Sharif’s radiant face. Hasn’t the public been led to believe that these hospitals are being erected and operated solely by the beneficence of our plutocratic leaders? Whence do these unknown low-level employees suddenly emerge as public villains to take the PR-bullet for our glorious leaders?
Because, I reiterate: complaints are far too often directed at the lower rungs of the workforce. This is usually a folly because even when something appears to the outsider as the fault of a specific employee, that fault is generally enabled by a system set up by those in power. Speaking locally in terms of a hospital system, it’s the consultants who must be blamed.
Consultants must be blamed, because it’s their job to take that blame. With great salary comes great responsibility. They don’t get paid more money for putting in more labour- their work is not more tedious than what an average nurse, house officer, PG or MO puts up with in the line of duty. They get paid to assume responsibility of things going wrong in the unit, because they are the conductors of the disharmonious orchestra.
A staff member does not run a medical unit. A team runs a medical unit, and a ball needs to be dropped by multiple staff members at multiple places for an error to occur. If an admitted patient dies from improperly prescribed medication, it’s more than just the prescribing doctor’s fault. A senior doctor either failed to countersign the prescription, or repeated the prescriber’s error. The nurse wasn’t paying attention to the patient’s deteriorating vitals. There was no pharmacist to raise an alarm.
The first thing you learn while practicing medicine in a developed country is the value of risk-sharing. You – the young, wide-eyed doctor or nurse – are not supposed to work around the system; the system is supposed to work around you. The system is supposed to take into account the inevitability of human error, and put reasonable safety nets in place. It is up to the consultant to create a system where errors are caught, rapidly reported, and corrected. It is up to the consultant to nourish the sense of team spirit, and inculcate an atmosphere where unethical and unprofessional attitudes are never normalized.
The relationship between an average junior doctor and his consultant in a regular Pakistani hospital, closely resembles that of a drill sergeant and a cadet. Anyone who has been to a Pakistani hospital knows how the air changes when a consultant walks into the room with an entourage of loyal junior doctors and nurses. Academic seniority isn’t subtly implied through medical practice; it is blasted at you with all the elegance of long-range artillery.
Consultants are often inapproachable; not just by patients, but by their own staff members. I recall my own experience working at a government hospital in Islamabad. A trip to the consultant’s office and the opportunity to bask in his hallowed presence, usually felt like the defining moment of the day. The consultant was the patriarch we all emulated. The consultant was the guiding light we all followed. If the staff ever had a particular ‘tone’, it was the consultant who set the baseline frequency.
In Pakistan, regrettably, our consultants mostly remain rooted in a time when behavioral sciences were not taught in medical colleges. They are artifacts of an age where grossly sexist, racist, homophobic, transphobic, and body-shaming attitudes were normal. On many occasions, I have found younger post-graduated doctors far more ethically aware than the senior consultants they take instructions from. I have had the privilege of working under some incredibly compassionate and hard-working PG doctors, whose counseling skills were inspiring.
Many consultants, on the other hand, have managed to convince themselves that their learning days are over. Clinical sciences and associated medical ethics, all evolve and adapt to changing times. These changes often go unnoticed by the anointed high priests of our medical orders, who are accustomed to working a certain way for many years. In some sense, their clinical experience works against them, because they not only have to learn new practices but unlearn previous inefficient ones.
I ordinarily refrain from comparing the developing world’s situations with systems in richer countries. But it wasn’t until I began working in the NHS in the United Kingdom that I fully realized the significance of a socialized healthcare system; a system that is built around teams, rather than masters playing their minions like chess pieces around the ward.
As long as these rigid hierarchies remain, it is essential that blame climbs up the tree as high as it can go. Only then will we be able to acknowledge the importance of developing horizontal partnerships, over vertical systems of overlords and underlings.