Sept 2017 Protest by doctors regarding Cabinet proposal in “malpractice”


“Thrashing” of doctors is a problem

Last week the Nepali cabinet proposed that doctors in Nepal be responsible for compensating the family of any person that dies under their care. The Nepal Medical Association called for a  “bandh” (work stoppage) in protest. Emergency rooms are open but other out-patient activities are curtailed. As of today, the bandh is still in effect. The cabinet will revisit their proposal when the Prime Minister returns from a diplomatic trip.

This is the latest chapter in a long-running problem also found in India, Pakistan and other Asian countries. Since 2011 I teach nurses and doctors in Nepal strategies to reduce the likelihood of getting thrashed.

You think of India as the home of Gandhi, right? Nepal is the land of Never Ending Peace And Love, isn’t it? Birthplace of Buddha?

At the heart of the issue is an ugly little aspect of South Asian culture. Here is what it is about:

If a patient dies while under a doctor’s care, the doctor is blamed. The family may assault the doctor, vandalize the hospital, and demand a large cash payment for the negligent care under threat of violence. Sometimes if the patient was associated with a political party, the local political chief will whoop up their cadre in a show of force to support the money demand. This form of mob justice happens throughout South Asia, to the point where it has it’s own euphemism “thrashing. (highlighting is mine, block quote added for emphasis).”

Thrashing

Thrashing is a form of frontier justice — if somebody commits a physical crime against you, you immediately convene your nearby friends with four-foot long sticks, and they join you in beating that person to a pulp.

Should doctors in Nepal carry handguns?

This is a big problem for doctors especially those serving in rural areas or in high risk specialties. In Nepal the doctors don’t want to assume this degree of personal risk. The problem is sufficiently widespread in South Asia that it has been reported by the India Correspondent of Lancet, the venerable medical journal from the U.K. and the India Medical Association proposed a bill in India’s parliament to allow doctors to carry handguns.

Political Feudalism

On another level, the local grandees of major political parties tend to get involved and will negotiate on behalf of the aggrieved party in exchange for a cut of the payout. There is a minimal malpractice system. The Nepal newspapers report on a what is now a well-publicized series of incidents in which this or that hospital gets vandalized or shut down by a mob on a rampage when there is no payout. In this blog I frequently record these incidents but they are too frequent for me to keep track of every one. The most recent seems to have been a protest at Om Hospital in Kathmandu, in which a woman died after surgery to repair a deviated nasal septum.

The above video is in Nepali. The protesters were presenting thoughtful views.

Here is another that’s a bit more raucous

I want to emphasize, I do not know the facts of the case. This particular event is added onto other recent events at the very same place, as reported in the media, and that magnifies this one. Any death of any person is tragic. Fortunately the protest after this one did not escalate into vandalism and violence.

Similar incidents have taken place at many locations, and Om Hospital is certainly not the only place!

Denial

There are many angles to the problem. One aspect is denial. As a tourist destination Nepal cultivates a certain image of happy hospitality and serenity, and this idea of thrashing does not reconcile with the image. So for a long time there has been a tendency to keep these episodes out of sight. Blame the doctor especially if they are young, but not change the system. Complicating this picture is that there is more than one level of medical training in the marketplace and there is in fact some degree of low quality medical care that qualifies as bonafide malpractice, just as we have in the USA. Also, there is a low level of medical literacy and many times the critically ill person arrives in the emergency room already dying because of delay in seeking treatment.

Life expectancy and maternal-child mortality

the life expectancy in Nepal is about 69.91 years. Maternal-Child Mortality in Nepal is high, about three times as high as that of USA despite a dramatic decrease.

This present crisis

The present brinkmanship was triggered by a proposal in Nepal’s Parliament to require that all doctors assume the cost associated with claims of malpractice. It was worded in such a way as to place 100% of the financial burden on frontline doctors. It does not address the problems of real or implied violence during the time when a resolution is being worked out. This policy if adopted, would negate the use of the judicial system to resolve these disputes which they are just starting to adopt. Here is the statement from the NMA from last week:

21616165_1544327605606092_6435817426469594615_n.jpg

On their website, the Nepal Medical Association wrote:

“प्रेस विज्ञप्ति

नेपाल चिकित्सक संघ केन्द्रीय कार्यालयमा आज बसेको संघको बृहत बैठकमा उपस्थित हुनु भएका विभिन्न विशेषज्ञ समाजका अध्यक्ष तथा महासचिवहरु, अस्पताल र मेडिकल तथा डेण्टल कलेजका निर्देशक तथा संचालकहरु, संघका पूर्व अध्यक्ष, पूर्व महासचिव र संघका बरिष्ठ सदस्यहरुको भेलाले गरेको व्यापक छलफलको निर्णय बमोजिम मन्त्रीपरिषद्को मिति २०७४ आश्विन २ गते बसेको बैठकले चिकित्सकहरुलाई लक्षित गरी गरेको निर्ण…यको घोर भत्र्सना र निन्दा गर्दछ ।

आजको यस बैठकले निम्न लिखित मागहरुको सम्बोधन नभएमा यहि २०७४ आश्विन ६ गतेदेखि  लागू हुने गरी देशभरका सम्पूर्ण अस्पताल, मेडिकल तथा डेन्टल कलेज, नर्सिङहोम, क्लिनिक लगायतका सम्पूर्ण स्वास्थ्य संस्थाहरुमा आकस्मिक बाहेकका अन्य सम्पूर्ण स्वास्थ्य सेवा पूर्णरुपमा बन्द गर्ने निर्णय गरिएको छ । यसको यथोचित कार्यान्वयनका लागि संघका सम्पूर्ण शाखा कार्यालयहरु, नेपाल भरीका सम्पूर्ण स्वास्थ्यसंस्था, चिकित्सक तथा स्वास्थ्यकर्मीहरुलाई यसै विज्ञप्ती मार्फत तयारी अवस्थामा रहन समेत सूचित गरिन्छ ।

तपसीलका मागहरु

१) २०७४ आश्विन २ गते बसेको मन्त्री परिषद्को बैठकले चिकित्सकहरुलाई मात्रै लक्षित गरी कानूनी राज्यको उपहास गर्दै गरिएको विवादास्पद निर्णयलाई अबिलम्ब सार्वजनिक रुपमा फिर्ता लिनु पर्ने ।
२) स्वास्थ्यकर्मी तथा स्वास्थ्य संस्थाको सुरक्षा सम्बन्धी ऐन २०६६ र नियमावली २०६९ लाई आवश्यक परिमार्जन गरी स्वास्थ्यकर्मी तथा स्वास्थ्य संस्थामाथी हातपात गर्ने व्यक्ति वा समूहहरुलाई “Jail without Bail (बिना धरौटी जेल चलान) को प्रावधानको उक्त ऐन तथा नियमावलीमा थप गर्नु पर्ने ।
३) नेपाल चिकित्सक संघसँग नेपाल सरकारले विगतका गरेका सम्झौताहरुको अक्षरस कार्यान्वयन हुनु पर्ने ।

विगतमा झै चिकित्सक संघले उठाउँदै आएको न्यायिक सवालमा समर्थनका लागि नर्सिङ, स्वास्थ्यकर्मी, नागरिक समाज, शान्ति र लोकतन्त्रका लागि पेशागत सञ्जाल (पापड), मानव अधिकार आयोग तथा संघ संगठनहरु, पत्रकारजगत तथा सम्पूर्ण बुद्धिजीवि एवं आम जनसमुदायमा यस संघ हार्दिक अपिल गर्दछ ।

नेपाल सरकारको यस्तो गैरजिम्मेवारपूर्ण निर्णयको विरुद्धमा संघबाट गरिने विरोधका कार्यक्रमबाट आम सर्व साधारणहरुमा पर्न जाने असुुविधाप्रति यस संघ दुख व्यक्त  गर्दछ र यस्तो बाध्यात्मक परिस्थितिको जिम्मा नेपाल सरकार नै रहेको जानकारी गराइन्छ ।

डा. लोचन कार्की
महासचिव”

They are stating the call to close hospitals in protest, and the demands are:
1. To publicly revert the decision of the cabinet
2. Jail without bail
3. To carry out all the agreements made between the NMA and the government.
CCNEPal perspective
I am on the side of the NMA in this controversy. The proposed rule serves to blame the doctors for a very complicated situation, and does nothing to move malpractice disputes into a judicial arena. That does not mean that changes from the medical side are not needed. From my experience teaching more than three thousand doctors and nurses in Nepal about this very issue, going back six years, I have some specific recommendations.
1) mandatory adoption of courses in Nepal that cover the same content as Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) (or PEARS).  All 4th year MBBS students need to be certified in this. Nepali doctors who receive their MBBS from abroad should be required to have these certifications before being licensed as a Medical Officer.
2) mandatory training of all interns and new MBBS doctors in situational awareness, counseling of patient party, and de-escalation techniques.
3) establishing a national registry of all incidents resulting in inadvertent death and thrashing or vandalism.
4) note that I agree with the “jail without bail” proposal.
5) requiring that all hospitals adopt building codes that support a controlled-access secure environment, and retrofit hospitals as needed.
6) Security personnel and local law enforcement agencies coordinate their activities.
7) Elimination of role of local political parties in negotiating settlements with local hospitals. Establishment of national fund for compensation.
8) strengthening hospital risk management systems to improve system response during sentinel events.
9) formation of a national study body to analyse trends in these incidents and share information.
Nepal is transitioning into more sophisticated medical services relying on hospitals, as opposed to the prior focus on primary care, and the educational system has not kept up with changing needs.
I encourage interested parties to browse my numerous past blogs and YouTube videos on this subject.
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About Joe Niemczura, RN, MS

These blogs, and my books, and videos are written on the principle that any person embarking on something similar to what I do will gain more preparation than I first had, by reading them. I have fifteen years of USA nursing faculty background. Add to it fifteen more devoted to adult critical care. In Nepal, I started teaching critical care skills in 2011. I figure out what they need to know in a Nepali practice setting. Then I teach it in a culturally appropriate way so that the boots-on-the-ground people will use it. One theme of my work has been collective culture and how it manifests itself in anger. Because this was a problem I incorporated elements of "situational awareness" training from the beginning, in 2011.
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