Aprons, Old Men, and Transfers

A SURPRISING EPIDEMIC.

The recent violent episode at SMHS warrants closer examination; from a cynical perspective. But first, we need to understand that violence against medical health professionals is unfortunately quite common. From Ethiopia [Africa], China and Turkiye [Asia], this unfortunate phenomenon is reported regularly. A recent study by Rodriquez in 2024 reported 16,866 cases of such violence in 2024, up by 103% from 2017. The only discussion here is what defines violence. Events like slapping a doctor are the more extreme manifestations of this phenomenon.

THE SOCIAL MEDIA STORM.

The event was quite worrisome in itself. However, the social media storm unleashed by the visuals has been even more educational. Almost every comment on social media that I have read shows a deep-rooted bias against medical professionals and a significant lack of understanding of the personal, social, educational, political, and financial aspects of health care in Kashmir. A hospital employee, morbidly, wrote that doctors should be hanged; a grave-looking middle-aged man, comically, declared that postgraduate students from outside the state are plaster technicians who have been given stethoscopes; another one mentioned that all doctors are thieves; and still another said doctors are inhuman and elitist. While social media has helped people find a platform to express their valid viewpoints, quite often, there is palpable ignorance about the issue being discussed. There is an element of insane McCarthyism on display here that should worry any voice. Hate is not going to get us anywhere. Kashmiris are often expected to be politically aware and mature, but the unrestrained commentary on social media reveals that nuance is often lacking in our discourse. It does not bode well for the future.

THE DEMOCRATIC AND POLITICAL RESPONSE.

Our democracies are flawed, but they do respond to public opinion. The alleged closure of the Accident and Emergency Department at the SMHS hospital would have been an entirely understandable response, except that there are no ‘no-go’ areas in modern civilization. Under no circumstances should the A&E area of any hospital be shut down. The act in itself is indefensible. The anger might have been roiling, but the armed forces and the medical professionals do not have a choice in this regard.

A relatable example that people understand is when one is trapped in traffic behind two squabbling drivers. You want them to fight away from the road and let others pass. The A&E department is an infinitely more important area. The slap was despicable, but none of the incoming or admitted patients were involved in it.

Understandably, the democratically elected administration took notice. So far, they seem to have taken three visible decisions.

1. Aprons and Nameplates: The SOP of wearing aprons and displaying nameplates is very hard to understand. Aprons evolved into medical practice as a means of protecting doctors from blood, body fluids, and splashes. There is some literature supporting the use of aprons as a means of building trust. However, the aprons are increasingly seen as carriers of infection and are no longer considered important. The older generations of patients still value a doctor in a white coat, but millennials do not seem to value it at all. And the white apron in a paediatric ward is frowned upon. There is a significant debate over the use of a long apron versus a short apron. And amazingly, research shows that the most trusted uniform in the A&E area of the hospital is the surgical scrub suit. The order has been served in such a way that it is akin to ordering the use of a prison uniform for inmates. If the apron had any impact on patient care, our doctors would be rushing to procure the most expensive and well-designed ones in the private sector. The private sector despite all its shortcomings is a good barometer to assess what works and what does not.
2. The Mass Transfer Plan: While transfers are necessary and do help develop healthcare immensely, no mass transfer program has ever yielded beneficial results. Mass transfers disrupt teams, increase stress and anxiety, and reduce quality care. And I make this observation across disciplines. These types of orders often arrive at the end of meetings, which can be self-flagellating. Ideas that lack in-depth analysis and debate. The government healthcare sector in Kashmir is among the best in India. This issue has been consistently reported in multiple analytical studies published in national weeklies. However, that does not make it perfect. It needs improvements across areas. However, these improvements must be evidence-based, consistent, and focused. A transfer plan based on workloads and lacunae is virtually non-existent. Comparing hospital outputs, the range of delivery, and staff strengths is critical before any decisions are made. The population and decision-makers must understand this basic fact. I recall the days when India was not a cricketing superpower. Our experts used to opine that the solution to the cricketing ills was dropping everyone except Tendulkar.
3. The Old Man and the Casualty: People often complain that senior doctors should be put on emergency duty. There appears to be some discussion about this being in the works. There is considerable evidence that supports the notion that the presence of a senior doctor improves outcomes in patient management. However, these studies need to be contextualised properly. A senior resident with two years of experience is considered a senior doctor as they are about to apply for faculty posts. The people want a senior doctor. A senior doctor is supposedly a doctor who is part of the faculty. I do not think the debate will end if a faculty member is placed on night duty. Eventually, there will be a call for the HODs to stay in the casualty as the old man has the maximum ability. The workload that many senior doctors are already facing is mind-boggling. Similarly, it is essential to recognize that a senior resident has a better understanding of the casualty area than a consultant. Cases that require additional care are always discussed and managed by the on-call consultant. Additionally, if the faculty is required to work night duty, departments across multiple hospitals will have to suspend indoor activities. Remember, the most critical surgical and medical cases reside indoors. The planners must develop dedicated assessment and simulation tools that demonstrate how healthcare could be compromised by acquiescing to this reasonable but ill-informed demand.

CAN THE TRUST DEFICIT BE REDUCED?

The doctor-patient relationship, interestingly, is a mix of trust and suspicion. A doctor bases his diagnosis on ‘suspicion’ after looking at the clinical picture. This suspicion helps him arrive at a diagnosis. Then the patient ‘trusts’ the doctor to intervene competently, even though he does not have a full grasp of the problem he is suffering from. Correctly applied, this trust-suspicion mixture is the beating heart of medicine. However, the rise of mistrust and suspicion of the doctors’ bona fides is threatening this relationship intensely. But we also know that people often use the sobriquet ‘sab chor hain’ for politicians, bureaucrats, policemen, and almost everyone else, too. But for this profession, this statement is horrific in its connotations. There is corruption in society, and this will be reflected in the actions of its professionals.

The moment society respects simplicity and hard work, corruption will become unappetizing. However, the vivisection of our social setup is a topic for discussion altogether. However, there is no doubt that a large number of hardworking, honest, and decent professionals are delivering services quietly and competently across Kashmir. The unfortunate fact is that such individuals are rarely discussed. The sobriquet that one often hears for such workers is that they are ‘simpletons’ who have been wrongly posted into the new millennium. It is essential to provide platforms for social reformers, religious scholars, thinkers, and achievers. Decent, self-effacing decisions are unusually attractive. And, the rule of law must be applied visibly and fairly.

DEMOCRATISATION OF MEDICAL EDUCATION

The opening up of MD, MS, MCh, DM, and FNB courses for MBBS pass-outs on a large scale has given a major fillip to healthcare all over India. Kashmiri students have been trained in colleges all over India, while students from other parts of the country have traveled to Kashmir for learning and training. This eclectic mix has been a great cauldron of exchange in terms of culture, ideation, and knowledge. Better-trained doctors are now available in every part of the country. However, there is a risk of a persistent language barrier in the A&E. This could be a source of stress and delay. It is vital to address this issue with sensible decision-making. As half of the students from the state quota are from Jammu, the language barrier is more pronounced than in similar government colleges in southern India. Globalisation has reduced the burden of this barrier, but the effects on A&E care require further study.

It is worthwhile to mention that the postgraduate who one sees working in the casualty is a vital cog in the overall patient care algorithm. However, current conditions mean that he is constantly worried about his career. The huge number of trainees allowed by the NMC has helped at a cost. The youngsters have very limited future prospects. Even something as natural as a senior residency has become increasingly difficult to obtain. Future financial security is extremely bleak. This is an aspect that needs continuous evaluation. Improving patient care is a moral obligation, but providing some sort of future security is also very important. One feels that the number of postgraduate seats should be reduced to maintain standards and allow more career opportunities.

Medical education is highly labour-intensive. It is considered the most demanding career pursuit worldwide. We owe it to our children to find a way that balances patient care with a young doctor’s career. I do not think doctors should elicit envy anymore. They deserve sympathy for going into a career with diminishing returns.

PROTOCOL VS BENEFICENCE

Our casualties do not run on protocols. The decision-making is based on the individual intelligence of the doctor on duty. While this does enable some incredible life-saving acts, it does not ensure uniformity. That is why the world has developed protocols for emergency care. This enables all treating doctors to provide safe, evidence-based interventions. Application of visible protocols would have automatically prevented the ‘plaster technician’ jibe from our wise old man.

The ATLS protocol was developed in response to a tragic event. While tragic or distressing incidents are best avoided, they are also critical for improving healthcare. In this discussion, we are discussing our A&E departments.

We still rely on beneficence during treatment. This brings personality issues into the picture. Personality traits in doctors vary. Sharpness, intelligence, empathy, communication, patience, persistence, and emotion can be different. It is often said that doctors should visit patients more frequently, spend more time talking to them, or be more empathetic. This is personality-specific. It is not possible for everyone to be visibly empathetic. That is why, while beneficence is desirable, it should not underpin our emergency healthcare. Solid, reproducible protocols ensure safety while dissuading brilliance. The discussion should focus on the necessary duty, rather than an ill-conceived utopia.

Srinagar has two main Accident and Emergency (A&E) departments. SKIMS Soura and SMHS. SKIMS does apply protocols in part, while SMHS is patchy in this regard. It is essential that protocols be updated and regularly assessed. I am not aware of any position papers about this from our authorities. Assessment of workloads, workflows, Patient Reported Outcome Measures [PROMs], Morbidity, and mortality. It would be delightful if our leaders attended a mortality meeting or an attendant meeting regularly, rather than holding forth in an inane number of conferences. I genuinely feel that the flow of information from both sides is not free and fair.

I will again lift an example from the traffic police department. Across the city of Srinagar, junctions have been overwhelmed by traffic, resulting in mega snarls. The traffic police have responded by using cones and barriers to streamline flow. The intelligent use of U-turns has helped alleviate problems at several locations.

The two emergency departments have been at it for ages. There has never been a concerted effort to develop two or three additional such departments in the valley. The entry points of major routes could be used to develop such centres. Small and effective. This could also divert the pressure from the main centers. The JVC hospital also has great potential to step in and help reduce the stress on these centers. The flow management could direct patients to the proper center. A composite electronic update and referral system is not too expensive to develop.

For this kind of thought process to take root, here are a few critical questions for our planners

1. What is the staff strength on duty at these A&E departments?
2. Is the staff use optimal? How does a department use nearly 20 faculty members, 12 senior residents, and around 45 PGs for improvement of patient care?
3. How can one help departments and organisations that are doing the same work with less than a fourth of this staff strength?
4. Can the staff be redistributed more efficiently?
5. What kind of workload are the residents facing?
6. Are all hospitals similar in terms of equipment and manpower?
7. What is the response time to redressal of grievances in terms of staff shortage and equipment procurement?
8. Are our casualty departments being monitored on the basis of proper, validated methods?
9. What is the incidence of cross-referral between hospitals for emergency cases?
10. What are the waiting periods for emergency cases?
11. Are our emergency OTs getting 15-minute breaks between surgeries?
12. Do we talk to our residents directly and collect critical feedback, or is it indirect and edited? Residents might give unpleasant feedback, but that is the brick on which efficiency is built.
13. Is the decision-making interactive or top-down?

This is just a small section of questions; answering them, and many more, could improve our future. I will make a seemingly unrelated but pertinent observation here. AI is not expected to have a significant impact on medicine, except in areas such as Radiology and Physiotherapy. For the foreseeable future, it is humans who must develop in planning and delivery. The sooner the stakeholders sit together and discuss, the better.

Unfortunate incidents like this should not elicit knee-jerk reactions from our administrators. The crowd might be baying, but the response should not be ‘off with his head’. The Alice in Wonderland example should be best left to Lewis Carrol.

Most of the planning is based on hard facts and solid brass tacks. However, I do visualise a utopia where the minister, the bureaucrat, the planner, the doctor, and the caregiver sit together, away from the cameras, and quietly discuss and debate with empathy about our patients, not for votes, not for fame, and not for money, but purely for basic human decency.

By: Dr Saleh Tabib