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.
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
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