Who are the doctors providing rural care?
In Nepal, the MBBS degree is an undergraduate program, four years followed by a one-year internship. The four years’ course is highly academic in nature, with an emphasis on reading and exam-taking. Only during the one-year internship will a young doctor examine patients, observe or assist in surgery, or write orders. After internship, the
doctor begins a career as a Medical Officer, then finally goes for Post-Graduate (PG) training – the equivalent of a Master’s degree which confers the title “M.D.” after their name. An MD becomes a senior attending doctor.
The “Charikot incident”
Recently in Charikot, Dolakha district, a toddler died after admission to the hospital. One report described it as a clear case of choking on a biscuit, but this is being investigated. The details don’t matter as much as the reaction. The family gathered a mob of three hundred people and the doctors were threatened. When the local authorities could not disperse the crowd, it is reported that they forced the doctors to stand in front of the mob and apologize. This was videotaped and posted on YouTube where it went viral and got more than five thousand views.
Al Quaeda in Nepal
A news article on an online site compared the Charikot video to the kind of hostage-taking video used by Al Quaeda. It was painful to watch six young doctors stand there making a “namaskar” gesture. I think every medical student could picture themselves being humiliated in similar fashion and it hit home. The Ministry of Health sent a
three-man team to investigate this whole affair, tasked to report in three days.
What everyone needs to know is that this is not an isolated incident and should not be treated as such. Though I am a videshi, I have a Nepali nursing license and I teach critical care skills when I am in Nepal. I have traveled in many regions of Nepal. Thousands of nurses and doctors have taken my course. I study the barriers to effective resuscitation in Nepal, and the course is designed to eliminate or mitigate things that get in the way of successful outcome. Since 2011, I have included training to help the team address aggressive behavior by patient parties. This includes use of role play and debriefing. I always ask if the nurses or doctors have experienced this exact kind of mob reaction while at work. Every experienced nurse or doctor has done so. There are hundreds of stories, and you would be shocked. Don’t think it only happens in Dolakha – incidents happen even in Kathmandu. For example two doctors got thrashed by an off-duty policeman at Patan Hospital last spring.
The vast majority of incidents do not get publicity like what happened in Charikot. The video makes it difficult to ignore, and all the doctors names have been published. This too is a shock. The local police seem to have failed. All such cases need to go to the judicial system. You can’t assume that the doctors were to blame. The international NGO that sponsors the hospital is also not responsible for the child who choked on his food. It’s easy to blame the
foreigners, but in fact the Board of Directors is mostly Nepali people.
A fair investigation needs to examine more than just “blame,” but by the same token, it can’t just conclude that the choking was a random event. Knowing what I know, I think it is time to look at the preparation we give these young doctors before we post them to rural Nepal. Everywhere I go I get a firsthand look at the MBBS course and internship, and I have learned that nobody in Nepal gets a course in Advanced Cardiac Life Support or Pediatric Advanced Life Support until their PG training. Most medical colleges or schools of nursing only
own one CPR doll, and nurses and doctors do not get hands-on practice with this. Nobody has ever watched them perform the psychomotor skills of resuscitation. This is clearly a gap that needs to be remedied.
There was only 1 doctor trained at PG level in Charikot. However, most of the other healthcare centers at the periphery are running without a PG doctor. For that reason, I conclude that the doctors in Charikot were doing what they were supposed to do. The best they could.
Upgrading of curriculum is needed
MBBS training at the level of fourth-year and internship year needs to be upgraded so that everyone who completes it can conduct a successful team resuscitation. No doctor should be given a rural posting until they have taken cpr, advanced life support, and pediatric life support courses. The same is true for the nurses. There are hospitals where
not a single nurse can do CPR or relieve a foreign body obstruction in a child. The nurses have never been trained. It sounds like Charikot was one such place. Resuscitation skills need to be performed by the closest person on the scene, and not reserved only for senior doctors. We don’t even know if suction or a bag-valve-mask was available in
Charikot. It would not be unusual for the hospital to only keep this equipment in their emergency room, not in the patient ward.
Ministry of Health needs to amend the national health plan
I proposed this last year when I was thinking of ways to ramp up my own program and help nursing schools and medical colleges adopt this. I was surprised to learn that no action could be taken to seek funding unless this specific set of skills was included in Nepal’s National Health Plan. It is not. Furthermore, many of the administrators who might be able to support an update to the plan are not even sure what resuscitation training is, let alone why special classroom techniques need to be adopted to teach it effectively. In my own course, we
teach counseling and de-escalation skills used in the eventuality of negative outcome, as well.
Nepali people who study MBBS in China get even less exposure to the hands-on skills. The lack of such training contributes to the difficulty that Nepal-trained doctors have when they compete for further specialized training in India or other countries.
If the Ministry of Health updates the goals of the national health plan to include a focus on resuscitation skills in medical college or internship year, it’s highly likely that foreign funding could be directed in this area, and the return on such an investment would be worthwhile for Nepal.
In coming years, Nepal will continue to think of posting new doctors in rural areas as a means to supply medical care in farflung regions. We owe it to them to give them skills to succeed and be secure. This is not the only strategy needed to address the problem, but it is an important one.
He is Principal Faculty of CCNEPal, and has taught 2,885 nurses and
doctors in 90 sessions of his course. His second book is a novel –
The Sacrament of the Goddess. In it, the doctors are confronted by an
angry mob after the inadvertent death of a mother in childbirth.
Niemczura studied the phenomenon of violence against health care
workers in Nepal intensively to write the novel. Find it on Amazon or
at Vajra Books in Thamel. Visit his blog
www.joeniemczura.wordpress.com for more info