A Truth Universally Acknowledged: Medical Negligence in Public Health Care
By Dr. Devika Brendon
Sri Lanka has universal health care. What this means in theory is that public health care and treatment by doctors and nurses is free of charge to patients in the public system.
What this means, in practice, is that those who do not have the financial resources to access private health care options have no alternative but to seek the assistance of doctors, nurses and medical personnel in the public system.
There is a great deal of fallout from certain ineffective processes in the current health care system, in terms of diminished quality of care offered to patients.
A friend of mine lost her sister after a standard surgical procedure that resulted in infection. It was a relatively ‘standard procedure’ in medical terms, but a serious matter for the patient undergoing it - a hysterectomy. No accountability was admitted to, and no responsibility taken. The surgeon refused to take the family’s calls.
Another friend of mine, herself a doctor, told me she had suffered a completely avoidable infection when a nurse in a reputed private hospital cut a suture with scissors taken from her own pocket instead of sterile dressing scissors. ‘I literally had no time to react or shout NO!’ my friend said.
Due diligence and extreme vigilance are required by patients faced with these kinds of lapses in the standard of treatment and care they are offered. Patients themselves are often in a weakened condition due to their illness, and are vulnerable as a result. So they need to have someone with them, who is prepared to advocate for them, and make sure their medical rights and human dignity are upheld.
There is no real peace of mind possible until the patient has recovered and is released to go home. This is confirmed by the direct experience of a doctor working in the public health care system in Sri Lanka.
‘When my husband was very sick with pneumonia he was under the best available care at NHSL. I was 34 weeks pregnant and sat on a stool next to him all night because of the fear that he might die due to the negligence of some of the nursing staff’.
Another lady told me that her niece died because of an avoidable error which occurred due to medical carelessness during surgery, which was not treated properly by those presiding over her procedure. This tragic outcome was preventable, and it was not possible, in the scape goating and gas lighting scenario that followed, to hold those concerned accountable.
‘In 2009, my 23 years old niece, who was eight months pregnant, was admitted with high blood pressure to hospital, and was given a C-section, during which they had nipped one of her large intestines which of course resulted in septicemia. The incompetent doctors had no clue as to what was going on, and it was too late to save her. As you know, septicemia treated immediately does not result in death; but those who were treating her had no idea, and when they eventually did, they tried to cover it up.’
Behind the lack of concern and care a patient in this system is unfortunately quite commonly faced with, are multiple systemic issues.
Consultants see multiple patients a day in the private sector due to poor pay in the public sector (private practice was approved in SL because the Government cannot afford to pay the salary according to the admin grade).
Self-referral of patients
The primary issue is that the skills of the consultants are accessed through multiple means, including self-referral of patients seeking expert opinion, instead of through a proper referral pathway. In other countries, your General Practitioner must refer you to the relevant consultant, after the appropriate tests are done. There is no such filter mechanism here.
Damned if they do and if they don’t, doctors who self-limit the numbers of patients who can consult them are often also blamed, because there aren’t enough doctors to meet patients’ demand. This situation would be far less vexed if there was a proper referral system in place. For example, one consultant neurosurgeon only sees patients on referral. He has limited the patients who he sees, to only those who actually need a neuro-surgical opinion.
There is absolutely nothing limiting a patient with a headache in Sri Lanka self-referring to a neurosurgeon, instead of a GP or Physician or Neurologist, which would be the proper referral pathway in the UK and Australia.
The notoriously long waiting times for patients are blamed on the doctors, but are actually often due to administrative issues. Doctors working in hospitals are emplaced in a situation which gives patients access to their skills in ways which maximise profits for the hospital. There is nothing stopping the hospital giving a tiered/staggered appointment system, which means multiple patients are booked in at the same appointment time. The pressure of time is then strong on the doctor to give a mechanical and brief consultation with minimum patient contact, and move on to the next one, in a form of conveyor belt medicine.
The vast majority of smaller private hospitals catering to the majority who choose private health care still only give an arrival time. There is no need for patients to be waiting for 3-5 hours for a 5-minute consultation. It should be possible for patients to find out the approximate time that their appointment will be coming up in the schedule list, and ask to be notified 5 or 10 minutes before by the hospital administration assistants. This would help mitigate the frustration and stress of delays.
Some hospitals demand that doctors take a minimum certain number of patient appointments for a day, saying they cannot cover their overheads. If the doctor is just starting out, it makes it very difficult for them to decline.
Low pay for doctors
A central issue is the low pay for doctors, even in the private sector. Doctors in Sri Lanka are aware that their medical colleagues in the US, UK and Australia laugh at consultants in this country for charging a fee of less than $10 per patient for their service, time and skill. (In the breakdown of fees, the major component is the hospital charge). But this is the case in many industries in this country, where professionals are forced to adjust their fee rates according to the lower economic capacity of their clients, relative to the training they have themselves received.
Many patients complain about the long waiting times to see a consultant in this country. For example, when a specific specialist procedure has to be performed, where the doctor in question is the only one with the extensive training needed, frustration often ensues. Although it doesn’t take very long, and it is not immediately apparent, multiple parts of the baby are seen and assessed and measurements taken, and a judgement given, regarding the situation in a foetal anomaly scan, for example.
When a doctor is known to be excellent, people they know personally, and the patients referred from the private sector, are naturally interested in getting an appointment with them. The lack of clarity and open access to the doctors in the current healthcare system means that doctors are overwhelmed with numbers of patients.
Self-restrict numbers of patients
Now there are several doctors who self-restrict numbers of patients per day, and have weeks to months-long waiting lists. This cannot be done for scans and other procedures that need to be done within particular time frames.
In this era of high social media usage, the social media posts expressing patient frustration would read something like: “I wasn’t able to get an appointment, and this problem was missed, and it could have been corrected. Why should the doctor restrict patients? S/he is duty bound to serve them.”
Many doctors have taken a decision to work even until the small hours of the morning to do tests and scans. This is at the expense of their own family life and their own health. And this is despite the prevailing recommendations they themselves give to their patients: that everyone needs healthy food, exercise, relaxation and at least 6 hours of sleep. They are putting themselves at risk for an early heart attack or stroke.
However dedicated a professional person is, working 18+ hours a day, even doing work you are passionate about, is challenging in a less than effective structure. Not when it’s 4-5 days a week, for the past 5-6 years and possibly for the rest of your working life.
Many doctors in this situation would prefer a good job in a big city in the UK, with a high salary, and a limited number of patients per day. To keep talented, skilled and dedicated medical personnel in the country, the systemic clinical administrative/support structure really needs to improve. Thorough training in communication and attitudes needs to be seen as essential, and sought after by doctors as part of offering professional best practice to the vulnerable patients in their care.
One of the present Deputy AGs, Dr. Avanti Perera, wrote her doctoral thesis in this area, and the thesis was published as a book titled ‘Medical Negligence in Sri Lanka’. So there is currently some realisation that systemic change needs to be formulated and implemented.
Social media has helped draw attention to actionable areas of improvement by providing a public forum in which the lack of accountability, poor communication skills, dismissive comments and uncaring attitudes of doctors are frequently brought up and debated. On FB and WhatsApp groups, doctors are frequently complained about by name, with specific details of complaints being mentioned.
Of course, it is entirely the right of patients to complain. However, as they lack insight into the systemic challenges faced by doctors, this unfortunately leads to lowered morale and confidence in the health system in the community at large. It has been noted that almost 40 per cent of the cases brought for complaint are due to poor communication between doctor and patient, rather than actual negligence.
While researching this issue for this column piece, I received a letter from a Sri Lankan doctor who had trained in this country, and is now working in the U.K. Her comments are worth listening to:
“I worked briefly in the medical league in Sri Lanka and sought ‘pastures greener’ over a decade ago. I was always fighting an inner battle with my conscience when I was working in Sri Lanka, and have found definite peace with my chosen calling in a different and satisfying atmosphere here in the UK.
I have shied against coming back to work in Sri Lanka mostly to avoid the confrontation it would require with the system in order to work there with a conscience.
I dread the situation for the common man and woman who has to deal with this on a day-to-day basis.
My parents are alive only because I wasn’t living in Sri Lanka and was able to demand what was necessary for their care. I shudder to think what would’ve been the alternative.
I would have liked to be brave enough to change the culture in the health care system I worked in, but it is not a decision to be taken lightly.
The first step would be getting enough people talking about it to make a change.”
It is my hope that this article will be part of that community conversation that prompts this change.
About the writer:
Dr. Devika Brendon is an academic, teacher, writer, editor and reviewer. She is the Consultant Content Editor for the SEALA Network, and Senior Content Editor of New Ceylon Writing, which was established in 1970 and brought online in 2016.