Until recently, doctors in Bhutan were indispensable. It is no longer
the case. Now, Bhutan has 244 doctors, 957 nurses, 514 health assistants and
many others that provide service to the people (AHB 2015). There are several hundreds
more undergoing training in neighbouring countries and they will join in the
service of the nation soon.
More doctors joining
the service in Bhutan is only one aspect of socio-economic development of
Bhutan. Bhutan is now professionalizing its human resources in fields such as
law, economics, engineering, agriculture, geology, etc. And not to forget, people
have easy access to information through mass media and social media.
The health sector has
achieved tremendous successes in multiple health indicators since the
introduction of allopathic medicine in 1961. The life expectancy has increased
from 49 years in 1994 to 68.9 years in 2010, infant mortality rate decreased
from 102.8 to and 30.0 per 1000 live births in 2012 and maternal mortality rate
decreased from 770 to 86 per 100,000 live births in 2012. Bhutan has also achieved
multiple successes in the Millennium Development Goals. How was Bhutan able to
achieve so much success in a short span of time? All through this time, Bhutan
had acute shortages of both financial and human resources while giving free
healthcare to all.
While we have achieved commendable
success in serving our people well. As a result, it was natural for people to
have increased expectations from the doctors, nurses, technicians and the
health system as a whole.
An example: A person in
the village wants to be seen by a doctor; a person in the district wants to be
referred to Thimphu hospital; a person in Thimphu wants to be referred abroad.
Now people rather wish to be seen by a specialist than by a generalist or a
junior doctor.
The health system in Bhutan – what all of us must know
There are several health systems that exist in our country. The
allopathic system of western medicine was established in 1961. The indigenous
medicine and many other local practices have been here for thousands of years.
The Ministry of Health promotes all of them. Each is an alternative choice to
the people.
Health is a delicate
condition. If you are healthy now, you can fall sick – so the preventive sector, the public health
measures like prevention of tuberculosis, vaccination programmes, sanitation
and hygiene programmes. And for those who are sick, their health needs to be
restored – so the curative sector,
the hospitals, comes into picture.
The hospitals in Bhutan
are three tiered. The Basic Health Units and District Hospitals are the nearest
to the people and are staffed by MBBS qualified doctors and nurses (not all
BHUs). If a case needs to be seen by specialist doctors and need better
facilities for patient care, they are referred to the Regional or to the
National Referral hospitals.
JDWNRH as a teaching hospital
Since 1974, the JDWNRH has been a hospital that provided training to
nurses and technicians. In 2012, internship programme for MBBS graduates was
instituted and residency programme instituted in 2014. Since then, in many of
the departments in JDWNRH, there is a hierarchy of doctors who look after the
in-ward patients.
The intern doctors are junior-most doctors who have graduated with MBBS
from Sri Lanka or Bangladesh, registered under the Bhutan Medical and Health
Council. These doctors, otherwise, would have qualified to work as intern
doctors under respective medical councils in Sri Lanka or Bangladesh. The
Intern Medical Officers are made to work in many disciplines of medicine and
treatment such as medicine, surgery, obstetrics and gynaecology, paediatrics
including radiology, ophthalmology, dermatology, community medicine, etc. This
programme is to give exposure to the Bhutanese context in order to produce
general doctors who can serve as jack of all trades in the district hospitals.
In the next hierarchy are the residents, who are undergoing a four year
specialist training in major departments such as medicine, surgery, obstetrics
and gynaecology, paediatrics and ophthalmology. The residents are those under
training to be a master of one.
There are specialists in many fields providing expert opinions in
patient care. They are the masters in their specialised field.
The road to having good specialist doctors begins with good intern
doctors. If our country needs more specialist doctors, for example, to perform
kidney transplant in Bhutan, we need at least few vascular surgeons,
nephrologists, intensivists, etc. who will come from the pool of current junior
doctors.
Do all cases need to be seen by a specialist?
Not all cases of patients need to be seen by specialists. There are
cases that can be treated by a general doctor and many people in the district
hospitals get good quality care from general doctors. In fact, in Sri Lanka, a
country barely richer than Bhutan in terms of per capita income, most people
are happy with the care given by their General Practitioners (GP), the general
doctors. These GPs sort out the minor problems and the specialists get time to
do what they are intended for.
Therefore, for our
patients in districts to get good quality care, it is essential for general
doctors to be competent in solving the problems that are solvable at the
district levels.
What else is different in the three tiers of
hospitals?
Besides the staffing structure described above, these three tiers of
hospitals have different capacities to provide service. More number of drugs
and better technologies are available at referral hospitals for the care of
patients.
The core of medical ethics
Allopathic medicine is a collection of best practices and scientific
evidence collected from the times of Hippocrates till now. Hippocrates (460 – 370 BC) is
the Father of Medicine and every health institution bears his portrait or his
pedestal.
A doctor is bound
professionally by the Hippocratic Oath to do to the best of his capability for
the best to his patient. In Bhutan, our cultural values of jampa, nyingje and jangchub sem are our guiding principles.
In addition, there are
four principles of ethical medical practice:
(1) Beneficience: It
demands that the health care provider should only do what is good for the
patient. A doctor may, based on his clinical judgement, decide that a chest
x-ray is of little use to the patient, while many an instance, people wish for
a lok-par because they do not know
what, why and when an x-ray in necessary to be conducted for a patient.
(2) Non-maleficience:
It requires the health care provider to do no harm to the patient. If a case is
not within the capacity of one doctor to manage it, it is his responsibility to
involve someone who is competent (someone senior, or someone from another
department) to manage the disease condition.
(3) Autonomy: Like
everyone else, the patient or the guardian of a minor has the right to decide
whether to accept the treatment. However, the right to decide for themselves
must come with proper understanding of the disease and the treatment by the
patient. However, currently in Bhutan, there is no specific legislation that
explicitly gives autonomy to patient.
(4) Justice: The
healthcare provider must think how best to provide justice. For example, to
produce an x-ray image, it requires what is called a plate on which image is
formed. If at a hospital where the government supplies limited number of
plates, why should a doctor do an x-ray on a patient who does not require it?
However, the medical
world is full of exception and anomalies. Supposedly, if a doctor didn’t do the
chest x-ray and failed to diagnose a chest disease, the patient can sue him in
the court of law.
When can a patient sue a doctor?
Currently, there are no specific laws that protect the patients or the
doctors. If a patient feels aggrieved due to the care provided by a doctor, can
you sue a doctor? Generally, in other countries, four of the following elements
need to be established to prove that there was medical negligence of medical
malpractice on the part of the doctor:
(1) Doctor-patient
relationship: There must be an established doctor-patient relationship. If
someone died while a doctor was just passing by his house, the relatives cannot
sue him for not doing anything because he was not his treating doctor.
(2) The doctor commits
an act of commission or omission: The patient party feels that an act of
commission or an omission has caused them harm.
(3) The person has
suffered harm due to the doctor’s acts.
(4) The causality of
harm to the person is established that it was due to the doctor’s acts. The
event of a hurt to patient or death of someone can be of many causes. In the
court of law, the reasoning of medicine is applied to establish that it was the
doctor’s act that resulted in death.
When does death occur?
A marvel of human body is that it has its ability to correct things if
they go wrong. However, this physiological ability to self-correct fails when
there is compromise beyond a point of no return. The role of a doctor is to
prevent the derangement from reaching this point.
Grief reaction
The loss of a loved one is a life-changing event in one’s life. There is
a series of emotional states a person goes through called the ‘grief reaction’.
The stages are first denial of the event, followed by anger, bargain,
depression and finally acceptance. The whole process in a normal person is
complete by maximum six months. If the grief reaction lasts beyond six months,
it is not normal.
In our culture, the
period of mourning and funeral lasts 49 days that brings kith and kin in an
event of show of social support that helps the relatives sail through the
bereavement phases. As doctors, we should be mindful that the event of death
that occurs in our wards, and that the hospitals herald a series of events in
the lives of close relatives.
The human value of life
A man is a social animal. We have a closely knit society with kith and
kin that come together in the event of illness. Doctors are entrusted with
social and professional mandate to preserve life. With increased expectations
of an ever more informed society, there is an increasing demand for doctors to
deliver god-like miracles to all ailments, be it of the body or of the mind.
Dr Thinley Dorji
MBBS
The views expressed in this article are that of the
authors’ and does not represent that of any of the organisations mentioned.
Published in the Kuensel, 05 November 2016
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