Dr Syed Mansoor Hussain

When I worked in the US, hospitals were strictly monitored and were expected to provide all the basic requirements of a cardiac facility. And more importantly, not only were my results monitored closely by the hospital but also by the state

The recent legal furore against prominent physicians from some of the better known private hospitals in Lahore seems to be simmering down. The law will eventually take its course but for a change, justice delayed in this case will not be justice denied. Medical malpractice is not murder. Negligence yes, even extreme in its consequences, but definitely not murder.

For instance, is the government or one of its agencies guilty of murder when people employed by it do not perform their regulatory duties leading to death or other serious consequences? Or worse, when decisions by those in positions of authority cause unnecessary death and destruction? Should we then not string up the secretary to the government or the general responsible?

In his famous poem, ‘The Charge of the Light Brigade’, Alfred Lord Tennyson says:

“Forward, the Light Brigade!
Was there a man dismay’d?
Not tho’ the soldier knew
Some one had blunder’d:
Theirs not to make reply,
Theirs not to reason why,
Theirs but to do and die,
Into the valley of Death
Rode the six hundred.”

But it seems that only physicians are to be held responsible for wrong decisions made often in good faith. A simple example is of somebody in my own area of medical expertise. As a cardiac surgeon I have performed more than 5,000 major heart operations. It is an accepted fact that in major heart surgery there is going to be serious morbidity and mortality of around five percent. This of course means that during my decades of practice, more than 200 people have died after I operated on them.

Now, if I had been accused of murder for all of them, by now surely I would either be rotting in a jail if not actually hanged by the neck until dead. The reason why I am still alive and out of jail is because I am pretty good at what I do. Also, I have been certified by one of the most prestigious organisations, the American Board of Thoracic (and Cardiac) Surgery as a specialist in this field. And more importantly, my results fall well within those expected of my peers in my area of expertise.

However, when I worked in the US, hospitals were strictly monitored and were expected to provide all the basic requirements of a cardiac facility. And more importantly, not only were my results monitored closely by the hospital but also by the state. As a matter of fact, my surgical results were published every year by the state I worked in. And yes, I paid more than a million dollars in malpractice insurance over the many years I was in private practice in the US.

In Pakistan everything is upside down. Hospitals — even teaching hospitals in the public sector — do not monitor results of the physicians on staff. If bad things happen, it is Allah’s will. In my specialty, I follow the rules established by the US cardiac societies about how mortality of surgical procedures is tabulated. Simply, all patients who die during the same hospitalisation or within 30 days of a heart operation are considered as operative mortalities.

However, in a recent conversation with the chief surgeon of the largest public sector cardiac hospital in Punjab I was totally flabbergasted when he insisted that for him and his hospital a surgical mortality is only that where a patient does not make it out of the operating theatre. By that criterion the reported operative mortality in his hospital is far superior to that of the Cleveland Clinic in the US, which happens to be one of the best cardiac centres in the world today!

So, the government of Punjab is putting out a health bill. Despite the fact that such documents written by lawyers and bureaucrats usually force me into a state of intellectual incoherence, I did read it in its entirety. In my opinion it seems to be quite reasonable but it does have two major deficits. First, there is no proposed regulation to monitor or record results in any of the private or for that matter public hospitals.

Second, it empowers an ‘inspector’ to do things that as they say in the old country would be entirely beyond his pay grade. I can well imagine what would happen when an inspector making Rs 40,000 a month meets a physician or a hospital owner making ten times that in a day. Who is doing the right thing then would be a matter of the heft of the envelope that passes between them. As is often said, you cannot legislate morality.

And now to perhaps the most encouraging thing that has happened over the last year or so, which is the emergence of an organisation referred to as the Young Doctors Association (YDA). Last week I had a chance to sit down and talk to the president, the secretary and the finance secretary of this organisation. During my discussion with them I did ask about what their priorities were.

Their first priority was that properly educated and trained physicians should be given preference to graduates of second rate private medical colleges. This is an interesting conundrum that I hope to address sometime in the future. Their second priority was that physicians in training should get a living wage. In this they were most appreciative of the present government of Punjab for having provided them that. The fact that I made all of Rs 80 a month as a house surgeon 40 years ago of course did not impress them at all.

Of course for them the most important requirement was that if they had to work in any hospital anywhere, they would expect that at least basic facilities expected of such a hospital would be available. And that takes me back full circle. The Punjab Health Care Bill does not define what a hospital should be.

Syed Mansoor Hussain has practised and taught medicine in the US. He can be reached at smhmbbs70@yahoo.com