Patient/Physician Relation: Doctors are also humans

Murtaza Rashid, Mudasir Firdosi, Shahnawaz Kaloo

The doctor-patient relationship is one of the most sacred relations. The patients’ trust their treating physician with secrets which they would not disclose sometimes even to their close relations. They trust the physician with their loved one’s wellbeing and life. Nothing probably can be more distressing than finding oneself or nears and dears in a hospital. There is uncertainty, nervousness, and fear of losing someone very close to heart. It can be a lifelong nightmare for a few. The patient expects someone to listen to their pain and agony. The wet eyes and frowned eyebrows are searching for a patient ear and saviour for a cure. Unfortunately, the patient-physician relation can turn ugly at times. We can attribute many causes to such conflicts but if we have an understanding of a few basic principles we believe most of these ill-timed confrontations are avoidable. The ideal patient-physician relationship is not limited to treatment only. It starts with trust. In turn, the physician also trusts the patient to comply with the given advice. Treatment is mutual. It cannot be one-sided.

Patients have rights which include:

1) Know details of his disease.

2) Best available treatment.

3) Accept or refuse treatment (if mentally competent and alert).

4) Know the Pros and Cons of the treatment.

5) Seek a second opinion.

6) Full privacy and dignity.

7) Take time to decide and think about the treatment.

Patients need to be responsible too. No treatment can probably be effective without the mutual understanding and acceptance of both patient and the physician. It is a collective effort. Responsibilities of a patient include:

1) Compliance to his treatment and advice of physician.

2) Preventive measures to stop spread the infection to others.

3) Be truthful to your doctor in each and everything even for non-compliance.

4) Do not abuse verbally or physically a healthcare worker if you are not happy with their services. There are laws to report such negligence.

5) Discuss your concerns with your own treating physician rather than others.

6) The whole team of physicians, nurses, health care assistants, and pharmacists to name a few are there to help you. Appreciate their efforts when due.

7) Respect the rights of other patients too. Hospital property belongs to all and needs looking after than deliberate damage.

 

These are the basic principles which must guide us to have an effective healthcare system. Many patients complain that the doctor came in, showing off to his juniors and nurses, and barely acknowledged I was there. ‘I felt like a stuffed exhibit in a museum’. Our healthcare needs to be patient-centric. Our duty as doctors is to tell patients about their problem, how it is affecting them, discuss a plan with them professionally and compassionately.  A patient may forget your name but he won't forget how you made them feel when they needed you most. Patients/attendants on the other hand too must listen patiently and respect hospital policies/timings. Our hospitals are overburdened. The doctor is a human being, with lots of responsibilities. Remember they can breakdown too. They are facing tremendous challenges daily due to non-availability or dearth of PPEs, medicines, equipment, beds, staff and other resources. They are at additional stress of catching infection and carrying the infection to their own families as well, hence putting their lives a risk for betterment of their patients. No doctor would ever want to harm his patient knowingly. Though we must emphasize medical negligence is not so uncommon. There must be stringent laws to report such episodes and rapid action taken against the offenders. Reporting such cases should be made easy and simple for the patients/attendants. An independent committee should thoroughly investigate the case. There are countries where medical negligence can lead to revoking a medical practitioner’s license temporary or permanently beside the financial settlements.  In the nutshell, as we mentioned earlier the patient-doctor relation is of mutual understanding and respect.

However, we cannot equate the healthcare system with a doctor. It is much more complex than what meets the eye. The healthcare system has been in shambles in Kashmir from a long time despite having dedicated and best-trained doctors. There is a lack of proper administration, organization, support staff, equipment, and medications, just to name a few. But any failure is usually ascribed to the treating doctor than the system as a whole which does not help. For example, the lack of an appropriate number of nurses on a ward or availability of a bed is an administrative issue which a treating doctor cannot sort out there and then. Unfortunately, for a relative of a patient in distress the doctor becomes the face of the problem and is usually at the receiving end of complaints and at times gets manhandled by emotive attendants. The pandemic of COVID 19 has brought this problem to its worst.

People are being advised to stay home and not visit their relatives in the hospital and rightly so and no attendant is allowed on the COVID wards as per the protocol. However, in a place like Kashmir where attendants do most of the nursing for the patients how will this work? Attendants care for basic needs, food, and water, call doctors, buy medicine from the market and run around to make sure the patient is getting reasonable help. If there is no attendant, who will tend to these needs? People cannot be left to die for water and food. Again, the protocols around COVID 19 are just bureaucratic without much professional input and thought. A place which does not have enough hospital beds and ventilators is putting every suspected case in hospitals and quarantine centres, strangely fumigating streets and houses creating more stigma than actually addressing the practical problems.

Even the best healthcare systems around the world failed to cope with the COVID 19 and we cannot do better if there is no reflection and reason in command. Sad incidents of people dying for want of basic care and unfortunate incidents of doctors being beaten by emotive relatives are just symptoms of the underlying longstanding problems of healthcare in shambles. The professionals need to be in charge of managing this extremely difficult situation weighing up what is possible and what not and how the limited resources can be put to best use than random pen pushers showing off their power. Sadly many people will die as this illness is still not treatable and is unpredictable. The stigma created hasn't helped either and is putting additional lives in danger as people are not coming forward and some denying the problems completely due to deep mistrust of administration. This is not surprising in a conflict zone like Kashmir where different rules are applied to different sections of people. The local population is being advised to stay home but tourists, labourers, and yatris coming from outside are allowed roaming free.   The civil society needs to rise to the occasion again to support each other and do whatever can be done in such dire circumstances. The hospitals and medical fraternity need support both morally and materially to make a positive difference and reduce the number of deaths by this dreaded COVID 19.

In the end, we must remember words of great Tinsley Harrison;

“No greater opportunity, responsibility, or obligation can fall to the lot of a human being than to become a physician. In the care of the suffering, he needs technical skill, scientific knowledge, and human understanding. He who uses these with courage, with humility, and with wisdom will provide a unique service for his fellow man and will build an enduring edifice of character within himself. The physician should ask of his destiny no more than this; he should be content with no less"

About the authors:

Dr Murtaza Rashid is an Emergency Physician, Saudi Arabia.

Dr Mudasir Firdosi is a Consultant Psychiatrist, London, United Kingdom.

Dr Shahnawaz Kaloo is a Consultant Radiologist, New Delhi, India.

http://www.risingkashmir.com/news/patientphysician-relation-doctors-are-also-humans-364074.html

Role of the religious bodies in containing Covid

Dr Murtaza Rashid/ Dr Mudasir Firdosi 

As of now Coronavirus outbreak has engulfed over three million people. There have been more than 300,000 deaths. Almost all the nations have been affected with enormous mortality and morbidity. Thousands are becoming jobless and economic recession is looming. Even the strongest of the economies are failing to cope up with the COVID 19 pandemic. Probably no one thought it would cause such a panic among the nations. Top international leaders were caught off guard. There was confusion all over. Everyone seemed unprepared. It spread like a wildfire. Major healthcare setups were shaken to roots.

A dearth of personnel protective equipment (PPE) and ventilators attracted headlines of almost all the print and the electronic media. Social media too was widely involved in narrating stories of the worst affected regions and highlighting lack of PPE.World Health Organization (WHO) and other leading experts started advocating social distancing.

Having no other option at the behest, countries one by one started ordering travel bans and lockdowns. The decisions to quarantine and social distancing were indeed hard to be made. People got stuck in foreign countries and non-native cities and villages.

The major gatherings we witness regularly are the religious ones. The four major religions of the world Christianity, Islam, Hinduism, and Judaism have billions of followers who usually perform group prayers at specific places. These places of worship where people gather in large numbers posed a major challenge for the governments and public health experts. The assembly of people at these places could easily lead to a person to person transmission.

The COVID-19 infection essentially spread by droplet transmission would have been detrimental by such a huge assembly of people.  People come in close contact and this would essentially have created a much bigger disaster than what we see at the present.  Hundreds and thousands of people visit different places of worship according to their faith daily, either located in vicinity or faraway usually as pilgrimage sites.

However, some of the holiest religious places are present in specific countries and people all around the world travel to such destinations where congregations could be in millions at a time. People have faith in their religions and it was not an easy task to stop them from visiting such places.

There were a few incidents when some people wanted to put faith in their creator for their safety than scientific advice. Also, there are lots of fake healers who exploit religion and sell cures even for COVID-19.  

As soon as the present crisis started unfolding earlier this year, both the governments and the people started weighing its consequences. It was evident from the beginning that humankind is fighting an unseen enemy.

With no vaccines or effective treatments available, prevention through social distancing remained the only recourse. Vatican City, the heart of the Catholics around the world with more than a billion followers, has roughly twenty thousand visitors each day.

As Italy was one of the first countries to be hit hard, the Vatican announced that it’s Holy Week and Easter celebrations ‘will take place without the presence of the faithful’. Most churches across the world asked the congregants to avoid physical contact and intinction.

Meanwhile, the Church of England also issued advisories and adaptations. The twin holy cities of Mecca and Medina in Saudi Arabia attract nearly twenty million pilgrims each year for Umrah (minor pilgrimage). Muslims all around the world usually come in groups to visit these religious sites.

As soon as the COVID 19 started spreading beyond eastern Asia, the authorities rightly suspended Umrah for international as well as the local pilgrims. Had this timely intervention not been undertaken, it would have caused an unimaginable catastrophe. In addition to that, mosques in the Middle East also suspended obligatory five-time congregational prayers and instead called upon the 'faithful' to pray at the homes. These were recited to them over the loudspeakers through azaan (call for the prayer).

Subsequently, most of the mosques world over asked the followers to stay and pray at home and fully cooperate with the competent authorities. The Muslim Council of Britain offered online services to keep in touch with the congregations.

India is home to near about a billion Hindus and second-biggest population of Muslims in the world. There are small and big temples scattered almost in each city and village. However, there are few temples and sites where Hindus come not only from India but from neighbouring countries too. 

Most of these temples like Shirdi Saibaba in Maharashtra, Jagganath in Puri, and Shri Mata Vaishnodevi in Jammu are visited by thousands of pilgrims daily. All of these temples were closed by the respective trusts. Famous Varanasi district banned Ganga arti (a special prayer) and yoga camps.

In a country like India with mixed religions and cultures, it is a humongous task to control all these activities. Hindus, Muslims, Sikh and Christian preachers resorted to social media to make appeals to their followers to stay inside homes and maintain social distancing.

This has been pretty effective and so far we do see a very less COVID 19 cases in India despite having such a huge population with diversity. Many gurdwaras also issued guidelines and advised devotees to take full precautions and maintain a safe distance. 

Jerusalem Israel, a city holy to Judaism, Christianity and Islam attracts thousands from all over the world. The ‘western wall’ is one of the most sacred sites in Judaism and thousands of Jews come to touch its stones and to pray.

The chief Rabbi urged the people to avoid gathering at the holy site. The heritage centre said that the visitors will be separated into prayer areas of up to ten worshippers with space between the groups. The concerned authorities removed the prayer notes between the stones and sanitized the wall.

The authorities also disinfected The Church of the Holy Sepulcher, which is revered by Christians as the site of Jesus’ crucifixion and resurrection. The visitors were strictly advised to avoid any act of devotion before and finally, the church was closed. The Islamic waqf council of Jerusalem also announced to halt the entry of worshippers into Al Aqsa mosque, Islam’s third holiest site.

Many countries and governments have issued lockdown's and curfews to contain the movement of people. It is quite understandable that to make such restrictions a success we need a positive public response. The appeals made by the religious groups have to a large extent made people stay at the home.

Without these guidance’s and adaptations, it would have been impossible to maintain social distancing. Although the proximity while attending such services is a major concern what makes it much worse is that the average age of people attending are usually older, the vulnerable population.

Epidemiological data has indicated that COVID-19 seems not to spare any specific age but affects significantly who are old with comorbidities. These congregational places could have been a hub of disease and spread it exponentially.

Almost all the religious groups have unanimously called upon restrictions on gatherings at the funerals or conducted virtual prayers. Many sports leagues and Olympics have been indefinitely postponed and these steps also strengthened the idea of maintaining distances.

Now as the curve of the Pandemic is flattening, people are worried about the effects of lockdown on economies and livelihoods of people more so in poor countries. Slowly places are being opened up with precautions. This also includes the religious places and if people are not careful, this can lead to the second peak of infections and COVID-19 related deaths.

On Sunday 31st May Pope Francis made the first-noon address from his window overlooking St. Peter's Square in three months as Italy's lockdown drew to an end. He called upon prioritizing lives over the economy, hence stressing the need for following physical distance and seriousness of the pandemic.

Similarly, the Prophet’s mosque at holy city of Medina opened up as well after 3 months to allow prayers. Many religious groups are advocating for allowing congressional prayers around the world. After so much pain, both mental and spiritual, any laxity in the efforts can bring the disaster back to any village or city in the world if people don’t take precautions.

As of now, there is no cure or vaccine in the near sight and keeping the physical distance may be the only way to hold the reigns of this pandemic. Each religion teaches human values and the preservation of human life. If there is a fear for one's safety we can refrain from what is extremely desirable ritually and make some temporary adaptations. We all belong to this planet and it belongs to all of us.

Pandemics do not choose any religion or sects. They hammer every region and country, all age groups, both men and women, regardless of having a religion or not. It is our collective effort to be successful in winning this war. We should not get misled by our assumptions and our thinking.

Stigma, fear, and blame game are not uncommon in such crisis either. Unfortunately, there were attempts to associate COVID-19 with particular faiths in some countries but overall the response has been positive and overwhelmingly understating. It is important to listen to those experts who are at the forefront of COVID-19 research. 

While people may start assembling again to fulfill their religious obligations, it is pertinent that rules and regulations are followed as any laxity can lead to further disaster. Let us win this fight together to make our planet a safe and happy place for all of our future generations. 

http://www.risingkashmir.com/news/role-of-the-religious-bodies-in-containing-covid

What should we do?

These are unprecedented times. We are worried, confused and distrustful. The
world is struggling to cope with the COVID 19 pandemic. There is no health system
in the world which can face the wrath of this unseen force. More than 760, 000 are
already infected and about 35, 000 deaths already and the numbers are increasing
day by day. The whole world has come to standstill, economies are crashing, people
losing livelihoods, and in some places, chaos is already setting in. Lots of rumours,
misinformation, fake news, and conspiracy theories, religious and other curses are
making rounds. Mankind is at war with himself. Countries which have far advanced
health systems and resources like the USA, Italy, the UK, and Iran are finding it hard
to provide appropriate treatment to everyone. What should we do in a place where
there is hardly any system and a makeshift administration? In times of such chaos,
you need a leader who people trust and listen to. We don’t have that either.

We need to be realistic. The health infrastructure, number of doctors, nurses and
other allied staff is nil to nothing when we look at the magnitude of this pandemic.
We cannot build hospitals like China did and even if we get some ventilators, there
are no intensive care facilities in most districts and who will operate them when we
do not have any trained nurses or paramedics available. The things are more
complex with COVID 19. Usually first port of call is a doctor or hospital when we
become unwell. Here if you go to the hospital, you can spread it to others including
the healthcare staff. There is no evidence that going to the hospital will help even if
you are tested positive. For those who do become severely unwell and need oxygen
and ventilator support, the prognosis is poor. In our setting, with a dearth of nursing
care, usually, families stay in the hospital, feed, nurse and buy medications from the
market. But here family members are likely to be infected if not symptomatic and if
not already infected, a hospital stay with an unwell patient will infect them. This
raises the question over who will nurse COVID 19 patients as there are not enough
nurses to do that job in Kashmir valley.

The authorities have just focused on testing and tracing people who had travelled
from outside state and this went to the level of propaganda, creating fear and
worsening preexisting stigma. Many people did not come forward with a travel
history and those put in so called quarantine, fled citing justifiable reasons like lack of
basic hygiene and putting dozens of people in the same room that feared likely to get
infected from each other. Even entire extended families of patients who died
because of COVID 19 are being put under alleged quarantine. This is not only
inhumane but hardly based on any scientific facts. Even in such pandemics, people
will need to grieve their dead.

Overall no one seems to be in-charge. One could have thought either director health
services or some other senior specialist from the public health or community

medicine will take the lead. Here we have different officials from the administration
trying to overdo each other without any thought or strategy. Demonizing people,
talking them down and then chasing them like criminals is not going help. There is no
focus on education; information sharing and making sure people don’t get inundated
by rumours through WhatsApp groups only. Can one fight a pandemic using the
decades’ old strategy of managing a political conflict with force and guns? No

What can be done?
It is time to be realistic keeping in view the infrastructure, healthcare staff and
magnitude of the pandemic which is only going to get worse. Everyone cannot be
tested or treated in a hospital. The virus has already spread in the community and
just focusing on anyone with a history of travel is not going to work. About 50 percent
infected do not show any symptoms but are contagious and carry on infecting others.
About 80% only have mild symptoms. So it is the asymptomatic people walking
around you who are spreading it as we speak. Everyone cannot be put in quarantine
or hospital and if we assume only 4 million will get infected out of 8 million; there is
no way of managing this pandemic in the hospital setting. If people are educated
and informed with clear guidelines with sincerity, most can stay home if having mild
to moderate symptoms of cough, fever, malaise and other symptoms. It is ideal to
test people to reduce contact and stress on self isolation in homes, but are there
enough resources to do mass testing.

Training and educating faith healers, peers, imams, and teachers and then using
them to propagate the message at the grass root level. Social distancing and self
isolation is the key to break the chain of spread from one to other. We know the
elderly and those with comorbid medical conditions are vulnerable with bad
prognosis. We have to buy time and protect the vulnerable in a hope that some
treatment or vaccine may be in available in the near future.
The healthcare staff and doctors need personal protective equipment (PPE),
otherwise we many lose may of them to illness and even death and if that happens,
we cannot deal with the pandemic for even few weeks. It is not enough to call them
god or bang plats for them unless there is an investment in healthcare and that
needs to be done now. Just focusing on buying new ventilators would hardly make
any difference if the healthcare staff is not protected in first place. The administration
needs to move on from the attitude of a police state to one of supportive to doctors,
rather than harassing them on the streets and beat them if they try to reach
hospitals.

Finally, people need to take responsibility. In this age, there is no dearth of
information. The internet is only partially restored but enough to know what to do and
what not to do. The infection is spread by droplets- coughing, sneezing, close
contact, hands, and aerosols in closed spaces. The virus lives on surfaces for hours
if touched and retouched. Washing your hands, not spitting in public, covering nose

and mouth when coughing, washing hands regularly, and keeping a distance from
each other is the best solution until we find a treatment. It is time to suspend
mosques, parties, weddings, offices, and any gathering completely. Funerals need to
be managed by professionals in full PPE as the virus is remains alive. These are not
easy times, people may not have food to eat, no jobs and income, so we have a
collective responsibility to look after each other and defeat this monster of a virus. As
Camus writes in his famous book Plague, ‘What’s true of all the evils in the world is
true of plague as well. It helps men to rise above themselves’, and I am sure we will
overcome this current age plague and be human again. Do not rely on hospitals,
doctors, peers, it is your life and only you can protect it for now by staying in your
homes and following the rules.

https://www.greaterkashmir.com/news/opinion/what-should-we-do/