The title for this article is taken from the motto above the doorway to the Morgue.
The Latin words translate as ‘This is a place where Death has much to teach those who are yet living’.
In days gone by, doctors used to swear a binding oath as a prerequisite to register in the medical profession. It was called The Hippocratic Oath, and a doctor, having graduated from many years of training, swore - before commencing their clinical practice - to do no harm to their patients, either by action or inaction, to treat each patient to the best of their ability, to secure the patient’s safety and privacy, and to pass on their skill to the next generation to ensure best practice and standard of care. The swearing of this oath is no longer a requirement for admission to the medical profession, although it was the basis for accountability in this vital industry.
Sri Lanka is very proud of its universal health care system, which provides free medical care for over 22 million people, from generally excellent medical practitioners. In fact, Sri Lankan doctors are known all over the world in the countries to which they have emigrated for their high level of skill, thorough professional training, and dedication.
However, in Sri Lanka itself today, the actual experience of seeking expert and timely medical care in the public system can be an ordeal for the patients and their families. This is important to know, because the powerful nationalistic narrative is that we are blessed to have universal health care - a public health care system which is free to all. In a nation where many are financially challenged, this is a blessing. However, due to certain factors inherent in the society as a whole, the quality of care offered in this much-praised system is often compromised.
In other countries, it is possible to book your loved one into a hospital and leave them in the care of the dedicated professional staff, confident that they will emerge well, having been appropriately treated and supported in their recovery. In this country, we have found this, unfortunately, not to be the case.
I have heard many accounts from multiple people who have had similar experiences to ours, with hospitals and doctors all over the country, and I believe it is a national problem. Because of the dominant narrative of universal health care being such a gift and an asset to the people, these individual cases are treated as one-offs. But each statistic represents a family: all the loved ones the patients have left behind, whose grief can never be repaired, as well as patients who undergo avoidable and needless suffering from mismanaged procedures.
The underlying reality experienced by patients is that there is no limit on how many patients a doctor can see for a clinical appointment and diagnosis/ treatment each day. Many doctors, especially consultants, see patients in multiple hospitals, and see more than 200 patients a day. There is also no designated minimum limit on the time period allocated for a patient visit, of 15 minutes per patient, for example, as in other countries. Many people say that the doctor does not even look at them or speak to them - they simply look at the patient’s charts or test results, and sign a form to authorize a script for medication. This is not humane medical treatment. It is a form of factory processing, with inadequate quality control.
If you are in need of serious medical help, and want to survive the health care system, make the effort to choose a doctor who is willing to give you a proper consultation, and is able to verbally interact with you and your family members. As a patient, you have rights: you have pre-paid your appointment fee, via channelling, cancelled your work commitments and waited for a long time - up to 3 hours at times - for your time with the doctor, to have your complaint and condition diagnosed. The least you deserve is for your consultation to be an adequate and thorough one.
Unfortunately, a high level of professional dedication cannot be taken for granted in a system like this. While many doctors and medical personnel do genuinely wish to care for patients, which is why they see so many patients each day, many others are wholly or largely motivated by the desire for personal enrichment. As a result, patients are not human beings to them, but numbers on an appointment schedule.
Many doctors are defensive about this perception, justifying their situation by pointing to the years of competitive exams and study required before they can qualify to practise, and asserting that they naturally wish to be rewarded for their efforts. But the result is that the patient must ensure that the doctor is not rewarded at their expense, and that of their family - not only financially, but in terms of the energy, anxiety and regret involved in unnecessarily losing a loved one, or witnessing their unwanted suffering.
Regrettably, the situation as patients in this system is that we should equip ourselves not only to fight illness, but to fight for our rights within the medical system itself. With such time pressures on them, doctors cannot be expected to diagnose your condition accurately. And many often do not recognize their own accountability.
This means that the patient and their family have to identify and fill in the gaps themselves, between the level of care that is required, and that which is available.
Patients in this system cannot afford to be ignorant. We must do our own research into our symptoms and ailments. Look into our family medical history, identify any risk factors, and keep a diary of our case, for our records. This will help explain our situation to the doctor, and also help us assess if the treatment we are receiving is correct. Given the heavy workload of the doctors, this is essential effort required from us.
It is not enough to go to your friends or social media. Look up reliable sources on the Internet, and medical text books. Ask doctors who you know personally for advice on where to do your due diligence.
Be aware that infections can often occur as a result of negligence, unhygienic practices and carelessness in aftercare, after surgery. It is difficult but necessary to be vigilant with regard to yourself, in your time of vulnerability.
The doctors and nursing staff in the hospitals are under stress, and are often rude, dismissive or even bullying to patients. This is unprofessional conduct. But because it happens so often, and without witnesses, it has become normalized. Often, stressed medical staff vent their own frustrations on those in their care. Be prepared for this. I have heard that some doctors even laugh at or mock patients who ask for information about what could make their hospital stay better for them, and that nursing staff are negligent, careless or deliberately withholding of attention if the patient is seen as ‘difficult’ for knowing their rights. Keep a record of what is said and done, in the interactions you have with medical staff, with dates and times, in a notebook. Take video or audio recording if necessary. Show from the start that you expect a high standard of care, to prompt them to give it to you. Keep in mind also that, contrary to the mythology of universal health care, in practice the social status of the patient in this country determines the quality and degree of care they receive.
There is very little chance that any valid complaint of negligence or malpractice against a doctor will be upheld in the current system. Unlike in other countries, where doctors are routinely held accountable, and have to prove that their conduct in any medical case in which they are involved was professional, and beyond question, doctors in Sri Lanka have disproportionate power in the doctor-patient relationship. Many believe themselves to be above being questioned, or held accountable. They will band together and support each other against patient complaints.
The rigid professional hierarchy operating within the hospital system enforces the culture of suppression of complaints or questioning. Some consultants are rude and abrasive to their juniors and nursing staff, as well as to their patients, relying on their own status and respect in the system to immunize them from accountability.
If a patient claims negligence in law against a doctor, the legal system is slow-moving and tortuous, and the outcome is not guaranteed. The insult of the legal fees, and the time and stress required for the patient to ensure that their concerns are represented, will be added to the injury the patient has suffered.
When you enter a hospital as a patient, and especially for surgery, you are in a vulnerable situation. Strangers will be designated to care for you, before, during and after your procedure. Their level of skill and dedication cannot be assumed. You need to know that the proper tests are being authorized and carried out, and that you are being cared for properly. From our experience, my family can say that the only way to ensure this is to accompany your loved one into the hospital, not only at admission, but during their hospital stay.
You may have to argue with the doctors and nursing staff to insist on the rights of your loved one, who may be too weak physically to do so themselves. You may have to question what is being done, or not done, and face outraged or annoyed accusations of interference or even disrespect for doing so.
Do not make the fatal mistake of assuming everything will be ok, and do not submit to bullying or intimidation. Insist on the appropriate care being given, at every stage. The only way to do this is to be physically present in the same room when medical personnel are in attendance at all times, except of course in the operating theatre. Be vigilant.
Most hospitals allow an extra bed to be placed in a patient’s room. I have been told that the availability of this has to be checked by the patient themself before admission. Some doctors don’t honour the patient’s right to request this basic support. From the beginning, know your rights. Show that you know them, or they will not be recognized or upheld.
The nursing staff may be ignorant or uncaring, or unskilled. They often lack sensitivity training. You know your own thresholds of pain and anxiety best. Make sure you have whatever you need with you to help you during the days of recovery, and don’t rely on them to administer it. They will not move to assist you without the head doctor’s authorization. And the head doctor is often not there to give the authorization when it is needed by you, because of their own busy schedule. The protocol and the hierarchical structure of externally-imposed responsibility within the health care system is more important to most doctors and medical staff than their personal accountability.
In fact, the punitive and blaming aspects fostered by the current system - and endemic in our society - are responsible in large part, in my opinion, for the total lack of personal accountability on the part of many personnel across many industries and professions in Sri Lanka. When anything goes wrong, or a mistake is made, people often engage in blaming and scapegoating rather than directly and honestly addressing the problem. They will never admit error or negligence on their own part, for fear of losing their job and their income. In the medical system, this is most serious, as any errors or mismanagement of your case can result in permanent or fatal consequences to the patient, who has no pathway of redress. And with no honest accountability, there is little likelihood of improvement, going forward.
It should also be noted that the private health care system is prohibitively expensive for ordinary wage-earners in this country, so it is not a viable alternative, and in effect the patients have no choice but to trust the care offered in the public system. Given this disempowering reality, the negligence experienced by patients by medical personnel is in fact a form of abuse. It speaks volumes in this situation that those patients who can afford it, including many politicians and those in the corporate sector, opt to have their personal surgical procedures performed in India or Singapore instead of locally.
In conclusion, it is important to take care when dealing with the hospital system in Sri Lanka. The patient, in addition to informing themselves of their condition, must try to pre-empt the challenges and difficulties they will face, as they seek professional care from often overworked and sometimes uncaring individuals, whose capacity to empathize and be compassionate to the vulnerable people in their care is exhausted, and frequently fails to adequately serve the sheer numbers of people they treat each day.
The recent Coronavirus Covid19 pandemic is a context in which people’s reliance on the dedication of doctors and nursing staff will become intensified. Citizens have been told to only come in person to the hospitals if they are extremely ill, and to manage their conditions at home to the best of their ability, as underfunded medical resources - in terms of apparatus, facilities, space, and personnel - are going to be under strain.
I wish the hospital my brother was booked into, with its basic facilities and inadequate support, had had the honesty to say that they did not have the facilities to appropriately diagnose and care for him, at the point of admission. He was admitted on a Wednesday, and by Monday he was my youngest ancestor. I had to identify his body at the Morgue.
Our heartfelt advice to all those seeking help in the health care system here is to educate yourself about your ailment, develop the superpower of self reliance, hold all personnel accountable to the best of your capability, and take responsibility for your own safety as much as you can - both in sickness and in health.
