The conversation at an evening soiree some years ago suddenly drifted to the question of who carries around a bigger ego—surgeons or climbers. There were arguments in favour of both: The climber has accomplishments matched only by a highly select group of individuals. The surgeons, on the other hand, are many more in number but their craft sets them apart from the rest of us ordinary folks. The difference though is that apart from occasional fisticuffs among themselves, mountaineers do not get bashed up by the public whereas with doctors, it has become a regular professional hazard.

After one of the more recent incidents of doctors at the receiving end, writing from a rural area in Gorkha, Dr Sudan Adhikari mused when his turn would come if he continued to practise in Nepal. He said that such thoughts were agitating the minds of all doctors in Nepal, especially since that they had decided to live in Nepal for a pittance of a salary compared to how their friends are doing in the United States, Britain and Australia.

One would have to have a block of salt ready to accept at face value Dr Adhikari’s assertion that all medics who have opted to work in Nepal do so voluntarily. There is no dearth of aspirants attempting to migrate abroad, mainly for further training but also to settle there permanently. Consider the United States. One indicator of the US as a preferred destination is the number of doctors who take the United States Medical Licensing Examination (USMLE). According to the World Population Review, Nepalis are the best performers in the USMLE internationally. Even so, just 21 percent of the doctors from Nepal who attempt the test get through. The OECD data on foreign doctors in the US states that a total of 1,537 doctors from Nepal had migrated in the two decades between 2002 and 2021. One can do the maths to figure out how many doctors actually want to head out—and that is just to the US.

There was a study from a while ago that looked at the graduates of Tribhuvan University’s Institute of Medicine, Nepal’s first. Covering the first 22 cohorts starting in 1983, it found 36 percent of them were working outside Nepal. The study also found that the lure of foreign shores was higher among the later batches, a finding consistent with a later survey of 147 doctors-in-training which showed that more than 50 percent planned to go abroad either for higher studies or work.

What was most revealing about the Institute of Medicine study was that those with “pre-medical education as paramedics were twice as likely to be working in Nepal and 3.5 times as likely to be in rural Nepal, compared with students with a college science background”. When one remembers doctors like the tireless crusader for a more equitable health system, Dr Govinda KC, or Dr Arjun Karki, the founder of the Patan Academy of Health Sciences and the brains behind the upcoming Nepal University, one cannot help but wonder if their own background as paramedics was what pushes them to not give up on Nepal.

Violence everywhere

But I digress here. More to the point is Dr Adhikari’s assumption that his doctor friends abroad are not only earning money and fame but doing it in the safety of a foreign country. Well, there is news for him. Just looking at the three countries he mentions so wistfully, one finds conditions are not much better there. An article by a former president of the American Medical Association cited government figures that showed injuries resulting from violence against medical professionals grew by two-thirds between 2011 and 2018. Even more alarming was the fact that health care workers were “five times more likely to experience workplace violence than workers in all other industries”.

The UK is not very different, with a 2021 survey finding “14 percent of all doctors experienced at least one incident of physical violence over the previous 12 months”. In the Australian state of New South Wales, a study showed that nearly 90 percent of the medical establishments survey had experienced verbal aggression and more than a third had actually had been subjected to violence.

Closer home, the situation is so bad in China that in 2014 the medical journal, The Lancet, even devoted an editorial to: “Violence against doctors: Why China? Why now? What next?” Five years later, a survey found that 85 percent of doctors in China continued to face some kind of violence at their workplace.

Violence against medical personnel has become a global phenomenon and alarming to such proportions that in 2012, the World Medical Association (WMA) had to address the issue of “Violence in the Health Sector by Patients and Those Close to Them”. The Covid pandemic made matters worse, and the WMA came up with a statement on “Workplace Violence in the Health Sector” in 2022.

Doc as God

The heartbreaking story of a five-year-old girl dying at Kanti Children’s Hospital after waiting for more than two hours for emergency care was an anomaly in the context of this piece since it did not involve doctors directly. More often, violence erupts in hospitals centres for the simple reason that doctors just do not talk to the patients and their families. As much is acknowledged by Dr Bhagawan Koirala, chair of the Nepal Medical Council (NMC), “Patients and their relatives should be communicated properly and health professionals should also behave responsibly.”

The NMC has a ‘Code of Ethics and Professional Conduct’ that aims to “protect the public and patient against medical negligence, medical malpractices and other professional misconducts”. But, according to a news report, although around 60 cases are registered every year, there has not been a single case of a doctor being penalised. The NMC’s registrar admits that doctors do not follow the code of conduct and actually compares them to bus “conductors” who push people while berating them all the time.

The WMA’s 2022 statement comes with recommendations that include crafting of policies by the state to ensure the safety and security of health workers and patients along with protocols for controlling violence in healthcare facilities. Equally importantly, it also recommends “ethical principles of healthcare and the cultivation of the patient-physician relationships based on respect and mutual trust”.

Likewise, the Lancet editorial concludes that the solution to violence against doctors “must come from within China, led by medical professionals themselves, most of whom have positive interactions with their patients… Just as reforms in China for land and education were premised on mutual rights and respect between actors, so too health-care reform needs to be built bottom-up with the full engagement of doctors and patients.” Everyone who has had the good fortune to be examined by a doctor with impeccable bedside manners knows what a world of difference it makes and that certainly appears to be key to better relations between doctors and patients.

There will always be crackpots who are not bound by decorum and would visit violence on their wives, their fathers, their doctors, anyone. Most people are otherwise reasonable. And while they might not wholly hew to an Indian court’s view that “doctors are the personification of gods”, when someone near and dear makes a recovery, they do come close to agreeing with that sentiment. The problem is some doctors behave like they believe they are indeed gods and us mortals too beneath them to deign engaging with.