Walking a fine line

“Are resident doctors really doctors?” was the title of an article that made the rounds online a month ago. Fely Sicam, writing for the Mindanao Times, composed a scathing piece deploring the way patients were treated in a “supposedly prestigious” public hospital in Metro Manila. Complaining at turns about the long wait and the arrogance of the healthcare personnel who received her, she wrote: “I guess if this is the situation in almost all hospitals in the country, 90 percent or even 99 percent who are patients in ERs will just die because nurses and doctors are not humane to patients.”

A number of well-written responses have also gone viral on social media, ranging from the calm and measured to the angry and petty. Both the original article and the responses have served to underline the current situation—that personnel in public hospitals are overworked and understaffed. Also, tiredness and the sheer amount of work are cited as the reasons for the ugly treatment that often welcomes patients in emergency rooms and outpatient departments. This association between workload and attitude has long gone unquestioned. After all, a number of studies support the fact that tiredness and lack of sleep are associated with medical errors. It doesn’t take much to conclude that snapped responses and snide remarks to patients can be traced back to the same.

I do not write to question this association but, rather, to challenge the attitude that my colleagues and I often take up when it is raised in conversation.

As medical students, we start out with varying degrees of excitement about patient encounters. Still, having been fed a number of Patch-Adams-like ideas on what a doctor should be, most of us would never dream of being discourteous to a patient. During our first encounters with patients we cringe inwardly at the long wait they are expected to endure as one student after another practices history-taking and physical examination on them. We apologize for taking up their time. We cling to every word they say. Maybe this word or that is the final clue that will lead us to that mysterious diagnosis. We ask where they are from, make small talk about our respective provinces, and document our first encounters with touching Facebook posts or ponderous blog entries.

We don’t stay that way for long. The transformation is slow but sure: Where we once took an hour to talk to one patient, we later take less than 15 minutes. Where we once cared about every symptom, we now interrupt them when we think the symptoms they claim are irrelevant to our clinical impression. Where there was once courtesy and even interest, there is now only the need to get the job done.

Maybe it’s a consequence of an improving clinical eye. Maybe it’s the result of being given more responsibility and more patients to see in the same amount of time. Whatever the reason, the result is undeniable: After graduation from medical school, for most of us there has been a profound change in the way we see our patients. We complain about the “toxicity” of our duties as measured by the number of patients who “disturbed” us during our shift.

Worse, we may argue with patients and their bantay, and snap at them for asking questions when we’re busy or tired. But what can we do? As doctors in training we are almost always busy and tired. This situation is coupled with the need to shell out money for patients in dire straits and with the academic pressure to study and get things done. Most of us accept it as part of public service. Some of us even brag about our capacity to turn into monsters. A lot of us regret it.

Still, in the light of Fely Sicam’s article and those that followed, one has to wonder: In defending our profession, are we also excusing rude and unprofessional behavior?

The problem of public hospitals being understaffed and underfunded is just one of the symptoms of a much-larger systemic problem. It isn’t exactly the sort of thing to be fixed overnight. It also isn’t the sort of thing a resident doctor—lowest in the totem pole, busy with grunt work—has a lot of power to change. However, it is my belief that tiredness, hunger and lack of sleep are merely explanations for the way we behave toward our patients, not excuses.

A lot of the articles responding to Miss Sicam came to the defense of doctors, asking the public to understand that we are only human. The failure in that (otherwise entirely correct) defense is that it may fail to take into account the humanity of those who come to the emergency room who are also tired and sleepless and hungry and who are—more to the point—worried about illnesses that they may not understand. Possibly, it may fail to take into account the humanity of people like Miss Sicam. Her ignorance is forgivable; our lack of sympathy may be less so.

This isn’t to say that perpetual courtesy to patients will be easy, or even possible, whether inside or outside the realm of public service. For some of us, it’s a daily struggle to be pleasant. Equally repulsive is the sycophantic attitude of giving patients whatever they want. As many doctors before me have written, patients are not customers; our goal is their good health, which does not necessarily correlate with their satisfaction.

The point is that, coupled with the knowledge that while rudeness has become the norm, there should be the constant awareness that it shouldn’t be. Maybe there is a fine, fine line between kindness and pandering, between firmness and discourtesy. I would argue that to walk this line is the duty of every doctor, whether inside or outside public service—whether resident or nonresident, whether “real” or “not real.”

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