The quality of medical care in the government-run hospitals is atrocious. This is true in the Punjab and possibly in most other provinces. Of course, there are exceptions but those are extremely rare. Much is said about how the present government is spending most of its money in developing Lahore. That might be true as far as mega projects are concerned but healthcare continues to be a stepchild.

Billions of rupees will be spent on building cancer and kidney and liver transplant centres but existing hospitals are completely ignored. This includes all the teaching hospitals in Lahore. Most importantly the present government cannot blame the previous government for the bad state of affairs. It is now eight years since ‘good governance’ descended on the Punjab and it now owns things, good or bad.

When we talk of the quality of medical care, three important variables are worth examining. First is the hospital or the institution or hospital that is offering the care or where care is being sought. This includes the physical plant, facilities including medical investigations available on site, and what might be called the philosophy that guides institutional practices. The philosophy depends on who runs the place and what they think is their responsibility towards the care of patients in their hospital. Here it is important to point out again that I am restricting this discussion to government-run institutions in general but also more specifically ‘teaching’ hospitals.

The second variable is the medical staff that is directly responsible for the care of the patients. This means all the physicians starting from the lowest level medical trainee going all the way up to the senior most consultants. Physicians might form the backbone of medical care but in modern medicine, the nursing staff is also an integral part of medical care. The level of training and the attitude of physicians towards the patients are important but nursing care today is becoming much more important especially considering the care of the sick patient.

The third variable is what might be called the cost factor. How much is the patient expected to pay for his or her own care? During the ‘previous’ bad governance that ran Punjab, much of medical care especially emergency medical care was made free in all government hospitals. In spite of wanting to do away with that the present dispensation has been forced to keep that in place. But the free part is being slowly whittled away since it is not an important part of present policy.

Each of these variables is important when considering the quality of medical care. But for today I will restrict myself to the physicians working in these institutions. The senior consultants set the tone. I have in the past often written about the fact that physicians have the same personal needs that other members of the community have and as such behave in most things as other people do in society. The major difference between physicians and other professionals is that physicians are expected to somehow behave in a more caring manner towards the people they come in contact. And more importantly this caring has to be present even when financial incentives are not involved.

For thirty years, I worked in the United States both as a trainee and then as a consultant cardiac surgeon. After my return to Pakistan, I worked as a senior consultant in Mayo Hospital in Lahore. The question I am often asked is whether doctors treat patients differently in these two countries. Interestingly, in my experience there is little or no difference in how doctors behave with patients except that in the US medical liability and fear of being sued is a major impetus for better ‘treatment’ of patients. An angry patient is liable to sue and that makes it worthwhile for doctors to keep patients and their families happy or at least as satisfied as is possible.

The other reason why physicians in the US are more responsive to the needs of a patient is that most patients have insurance and so most doctors will get some remuneration for the care they provide.

During the time I spent working in a ‘public’ teaching hospital in the US where most patients were charity patients, the behaviour of trainee physicians was not very different from what I saw in Pakistan. However, senior physicians were much more careful in their attitude towards charity patients. And yes even charity patients can sue and in a teaching hospital the person that gets sued is obviously the consultant and not the trainee doctor. As such senior consultants teach and then expect that their trainees will behave appropriately with the charity patients. Sadly, such behaviour is neither practiced by nor taught to trainees by present day consultants working in the public sector.

Pakistan is not an egalitarian society. Differences based on wealth and social status are still very important to most people. This attitude is particularly evident in senior doctors that have not received any medical training abroad. Medical training in western countries not only is much better than that is mostly available in Pakistan but having worked in a more egalitarian environment does make most physicians a bit more receptive to the needs of all patients irrespective of their social class. However, many senior consultants that have trained abroad do tend to lose some of those behavioral qualities with time spent in Pakistan. But the one thing most foreign-trained doctors rarely lose is the habit of treating all patients the same way as far as medical treatment is concerned.

Most of the physicians graduating medical college more than a few decades ago were taught and trained by doctors almost all of whom had received advanced training abroad. A lifetime ago when I was a final year medical student in King Edward Medical College, during an in-house test our group of students were asked to examine a group of patients to demonstrate our clinical examination skills. When my turn came, I had to examine a young woman. I forget what her problem was but I remember one thing. After I finished examining her I carefully pulled up her bed sheet cover over her. My professor said to me that however else you did in your clinical evaluation, the fact that you treated the patient with such consideration is enough for me to give you an excellent grade. That sentiment has stayed with me for almost half a century and I have tried to pass it along to my trainees over the years.

To sum it up, many senior consultants don’t really care about ‘non-paying’ patients in public hospitals and this attitude gets passed on to their trainees. These patients are then treated indifferently and with little respect by the trainees and lower level medical staff. Sadly this attitude even filters down to the level of nurses taking care of these patients. The second major problem is that the trainee doctors are being inadequately trained. Since many locally trained consultants are poorly trained themselves, it becomes a matter of the blind leading the blind. More about all this next time.