Doctors in Pakistan: Sumbal, only the peptic ulcer wali bibi, not a person with feelings

Published: February 19, 2014
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Our patients trust us enough to submit to the most uncomfortable and embarrassing examination procedures we can subject them to.

Her doctor thought she was an open mouth for him to dunk pills into. Instead, she turned out to be a person with thoughts, feelings and questions that were all left unaddressed.

As part of Pakistan’s tightly-knit community of doctors, it is common for us to share our horror stories about non-compliant, abusive patients with laughable misconceptions about drugs and bodily functions. We softly giggle at them mistaking left-sided abdominal pains for appendicitis, when the appendix is in fact on the right side.

And the unspoken conclusion drawn each time is that a patient is too uninformed to be trusted with his own medical decisions. Thus the standard operating procedure in Pakistan is for the doctor to hijack the patient’s body and do unto it whatever he thinks is best.

In a recent blog post, one mentions a woman complaining about her nephew’s chest being assaulted by doctors – a manoeuvre that turned out to be life-saving CPR.

Was it not incumbent for the doctors to explain to the attendant the kind of procedure they were conducting? Or at least do so later at the first available opportunity? If someone walks up to you and starts pounding your chest, wouldn’t you ask,

“Pardon me for being so nosy, good sir, but what on holy earth do you think you’re doing to me?”

Rather, they acted as if the adult guardian had entirely surrendered the child’s anatomy to the doctors, to do with it whatever pleases them – no questions asked.

But there were questions to be asked and the family left the hospital believing that their child had been attacked when, in truth, the doctors had probably saved his life. This dictatorial approach cost the concerned doctor his rapport with his patient, even if the procedure he performed was fully justified.

Something similar happened to Sumbal, an uneducated young woman not dissimilar to countless others who walk into our clinics each year. She requested an ultrasound for upper abdominal pain. That being an unnecessary test in the given case, the doctor sternly brushed her off with a prescription for anti-ulcer drugs.

Outside the doctor’s office, her eyes welled up with frustration. It wasn’t, I expect, because the doctor was rude but because of how incredibly small he made her feel; making it obvious that her feelings were irrelevant before his medical degree and that she should simply put a capsule in her mouth and zip it.

Inside the office, she wasn’t Sumbal; she was the peptic-ulcer-walibibi, and treated precisely as such.

She had questions.

Wasn’t the ultrasound a superior therapeutic tool?

Was the medication ‘hot’ or ‘cold?

Would it affect her reproductive cycle?

All questions were based on the horribly flawed understanding of the drugs and diagnostic procedures, but it was the doctor’s job to clear them up and send her home, at least, partly satisfied. This is where the subject of Behavioural Science he grudgingly studied in medical college had to be practically applied.

I doubt this patient took those Proton-Pump Inhibitor (PPI) capsules. She probably chucked the prescription out and went back to whatever traditional remedies she had been using.

Outside our community of doctors, an average Pakistani mumbles about greedy, incompetent doctors who don’t really care about their patients. Within our community, we decry foolish patients too uneducated to comprehend the wisdom of our ways; those hating us for not having the divine authority to defy death in all cases.

Who’s really to blame?

I turn the finger at myself, not because I’m greedy or incompetent, but because I’ve done a lousy job convincing my patients about how my decisions benefit them. I’m part of a system that not only bestows little value to the art of keeping patients satisfied and compliant but is also so congested that it leaves me little time to provide each patient the attention he or she deserves.

Our patients trust and respect us enough to submit to the most uncomfortable and embarrassing examination procedures we can subject them to.

The least they have is a right to be informed of what’s being done to their bodies.

Faraz Talat

Faraz Talat

A medical doctor and bubble-wrap enthusiast from Rawalpindi, who writes mostly about science and social politics (and bubble-wrap). He tweets @FarazTalat (twitter.com/FarazTalat)

The views expressed by the writer and the reader comments do not necessarily reflect the views and policies of The Express Tribune.

  • http://KashifMD.com Kashif Chaudhry

    Good piece Faraz. As a fellow doctor, I agree that we do not inform the patients and educate them as much as we ought to. This is especially true for Pakistan. In the US here, patients are generally well educated on their condition and more aware.

    One issue, however, that doctors in Pakistan face is time constraints. The patient/doctor ratio is too high and outpatients/inpatients are usually flooded. Doctors are pressed for time. This might also be affecting the time allocated to patient education. Hope things improve.

    Thanks for writing this piece. Recommend

  • Unknown

    Finally, a good blog from a doctor. Good work, keep it up.

    When I was in Pakistan, I took the doctors as they are, rude, no feelings, and pathetic. Me with my baby whose age was only few hours at that time, were so rudely behaved by the doctor that I didn’t believed that they are human. In USA, I have seen real doctors and nurses and I wish Pakistani doctors and nurses should learn some human values from them. Rotting the diseases names and their cures can make you a doctor (kasai) but not a massiaha. Recommend

  • V

    Thumbs up for writing an unbiased piece on the issue. This is probably the only balanced blog I have read on the issue.

    However it would be nice if you could suggest some improvements and solutions. Do you think an Urdu and English database of diseases with symptoms accessible online or through cellular phones would help mitigate the gap of knowledge between the doctors and patients?

    I think the doctors are better equipped to solve the issue as the overwhelming majority of the patients are too illiterate to search online for the symptoms of the ailment they maybe suffering from and find the likely cause.

    Thanks for taking the time to write this though!Recommend

  • Nishant

    i have seen this vary from doctor to doctor, but whatever my experience says (i have been in an out, weak immunity and accident prone fate) that most doctors(especially government) , when they meet a patient say from a village or old people(they tend to become stubborn or sathiyana), they try to explain things, the medicines, precautions and insistance on follow up in layman languages often even to hilarious results, which are shared among colleagues(babuji yeh dawai ek bhi din chhootni nahi chahiye, nahi tou double dose leni padegi, yeh dawai khalee paet hi lena warna fayda nahi hoga, etc.) Recommend

  • A Pakistani

    Excellent blog. I hope and pray for the day when our medical industry starts thinking on the same lines.Recommend

  • Parvez

    I hope you practice what you preach because that will be the beginning of you becoming a good doctor.
    There are few doctors who care to explain what is wrong and how they will fix it and how the medicine will work……..my family GP was one such doctor, sadly he’s dead now and over these many years I still have not found a doctor such as him. Recommend

  • Asma farooq

    Nice blog , it’s kind of un resolvable issue for pakistan . Where doctor/patient ratio is high . Government hospitals are flooded by patients . 85% patients are illiterate . Plus most of them are not willing to understand their current situation . Same Pakistani doctors working abroad are following ethics strictly , which absolutely means we have flaws in our system . So we should curse our system not doctors . Why almost every doctor in pakistan wants to work abroad ? When you have to see almost 300 patients a day in opd with a handsome pay of 50,000 , Anyone can loose temper . Government should raise the pay , doctors will provide a better result because they also have a family at home .Recommend

  • gp65

    Well written. The crux of it was “Inside the office, she wasn’t Sumbal; she was the peptic-ulcer-wali-bibi, and treated precisely as such”. As you correctly guessed, compliance improves greatly when patients understand what the diagnosis is, the basis for reaching that conclusion and what are the consequences of not complying with the doctor’s advice. This dialog can even improve tthe diagnosis and reduce error because if there were incorrect assumptions a doctor made, the patient can correct them if they understand the basis of the diagnosis.

    @KashifChaudhry: I would agree that the type of treatment that patients (by and large) in the subcontinent get is not as respectful as you might get in the US. You indicated that time is a constraint but with the insurance push on number of pateints a doctor particular family physician needs to see, they too have a time constraint. The bedside manner is often missing in the subcontinent. In fact the absence of communication skills can also be observed in other fields such as software engineering where focus on technical skills comes at the expense of communication skills which are equally important.Recommend

  • http://@net Hunza wala

    @Kashif Chaudhry:
    Mr Chaudry, step out of your little revery. And consider
    an emergency intake/ward of any major city hospital in
    the US. Shall we say Cook County medical facility in
    Chicago. Or perhaps you might prefer to check Harbor
    General in LA? Maybe Olive View in LA County. Miami/Dade?
    Very likely you will redefine patient/doctor ratio.
    And inpatient/outpatient, flooded?…. there you would call it an ocean!
    A far cry, say, from a little countryside hospital in New Jersey.Recommend

  • http://@net Multani

    The author has written a very condescending article.
    There is a rumor going around, that doctors in this country
    have a reputation. Arrogant and rude
    The episode about ‘..chest being assaulted ‘ [CPR]
    So your observation about CPR was being administered,
    with punching or slamming the chest with a fist, is very
    flawed. Belongs in hospital dramas on TV.Recommend

  • Faraz Talat

    Multani,
    I hear what you’re saying, but you don’t have to convince me of the indications and importance of CPR. It’s the patient who needs counseling, because she obviously thought that the procedure seemed a little too violent to be considered safe. I was narrating her experience.

    I know doctors aren’t any more arrogant or uncaring than any other workforce. But as I said, they have done a poor job explaining themselves to the public. It’s not just that the doctors are at fault, but the system itself that is underfunded, overwhelmed with patients, and apathetic about patients’ autonomy over their own bodies.Recommend

  • http://@net Chakwali

    @Faraz Talat:
    Here is part of the Hippocratic Oath. [the second to last line, from original]
    Doubt very much if you are familiar with it. Since you have not taken it.
    ” All that may come to my knowledge in the exercise of my profession or in
    daily commerce with men, which might not be spread abroad, I will keep secret.
    And will never reveal.”
    Which means you do not make hay with uninformed patients perceptions. Or fellow
    physicians lack of moral and ethical values or decisions.Recommend

  • Chakwali

    Here is part of the Hippocratic oath. [Next to last line. From original.

    ” All that may come to my knowledge in the exercise of my profession
    or in the daily commerce with men, which aught not be spread abroad,
    I will keep secret and will never reveal.”
    Which means, do not make hay with uninformed perceptions of patients.
    Or reveal the lack of moral or ethical values of fellow physicians.Recommend

  • Faraz Talat

    That clause pertains to doctor-patient confidentiality (which I have honoured, as “Sumbal” is a made-up name).

    We are not obliged to cover up other physicians’ unethical practices or flaws with the healthcare system.Recommend

  • Chitrali

    Since you have your own interpretations about honoring
    the Hippocratic Oath, with no qualms, please consider this:

    If and when you ever receive your degree. Kindly export
    yourself to…say Papua-New Guinea. Perhaps Myanmar.
    [formerly known as Burma] maybe even Mali. They are
    very relaxed about oaths and rules and such.Recommend

  • Lucid

    Finally a good article by you.kudos!! we need more empathic doctors in this country.Recommend

  • M Ali

    “giggle at them mistaking left-sided abdominal pain for appendicitis when the appendix is on the right side”, never heard of radiating or referred pain then? Seems like someone needs to go over their pain history again dr sahab :pRecommend