Ghana is one of the more stable and prosperous west African countries. It has just about 3450 doctors for 23 million inhabitants, giving a ratio of about 0.15 doctors per 1,000 people (Ghanaian Health Stats). There does seem to exist a volatile and hostile relationship between doctors and their patients in the country (Lambon). The purpose of this paper is to explore the various possible reasons behind this hostility and discuss the possible means of its resolution.
Doctors are among the highest paid earners in a population where at least 70% of the population subsists on less than $2 a day. They are expected to spend the first two years after medical school doing their “house job,” which is working in public hospitals as service to their country and under the tutelage of consulting physicians to further hone in their medical skills. A newly minted house officer can expect to take home between $630 and $700 a month after taxes (F). Based on their contracts, they also receive up to $100 monthly as food allowance and other sums of monies as fuel allowance and other types of allowances.
Public Perception of doctors
In the eyes of the public, doctors are often seen as “greedy bastards” (Lambon) who are always on strike demanding more money and who don’t particularly do their job in any case. I worked at Sunyani regional hospital in Sunyani, about 9 hours drive outside the capital city of Accra in July and August 2010. There I had the opportunity to interview and converse with several doctors about their perception in the public and what could possibly be done.
A House Officer’s Schedule
Dr. B. Dr. Z, and Dr. A are all house officers (Dr. B is in his second year house job and Drs. Z and A just started their housemanships about six months ago) at Sunyani Regional Hospital. The hospital, although far from “modern” by any standards, is considered the tertiary medical hospital1 for the Brong Ahafo region2). Yet there are only about fifty doctors in to total working at the hospital, with fewer than twenty house officers. One realizes how untenable this situation is when one understands that generally it is house officers who do the bulk of hospital work, as residents and consulting physicians have other duties too; a house officer’s sole duty is to ‘take care of the house’ – patients. Thus for a regional hospital nine hours outside of Accra to have less than twenty house officers would mean that the doctor patient ratio would be even less than the 0.15 per 1000 population enjoyed in more urban areas of the country.
Dr. A noted that her days were much like any other house officer’s: hectic. Her mornings start at 8:30 am with doctors’ meetings, after which, if there is time, a 15-minute breakfast break is taken. From there, she is off to the wards to see her patients. Ward rounds can take anywhere from one hour to over 8 hours, depending on many factors like how many patients there are, how many emergencies there are, who is doing ward rounds, etc. An hour of lunch break is permitted after ward rounds, but very few of the house officers take it. From the wards they head to the out-patient department, where they sit and attend to out-patients. Ostensibly their schedules are supposed to run until 4pm, but most house officers do not leave until they have attended to every out-patient and sometimes do not leave until well-past six. Sometimes, after work at the out-patient department, Dr. A has to work at the emergency room from 4-9pm, other times, after work at the out-patient department, she has to work at the emergency room from 9pm-9am, but regardless of her shift at the emergency rooms, is expected back at work in the wards at 9 am every morning every day. In addition to that, because she is the house officer, she is the officer on duty – her ward may call her at any time of the day or night to deal with an emergency or certify a death. Drs Z and B share much the same question.
On 28th July 2010, around 10pm, Dr. A was called to the ward to deal with an emergency. After her services were no longer required, she decided to pass by the emergency room. Dr. Z, who had reported feeling ill, was the doctor on duty that night. Dr. B had been called in to stitch up a patient. Dr’s A and B stood in the patient waiting area chatting, and stopped Dr. Z as she passed by, to exchange pleasantries, ask after her illness, since they has noticed her looking sickly during the day, and tease her about how obviously exhausted she looked. Dr. Z laughed, stayed to chat a few minutes, and then walked back into the emergency room to attend to patients.
All the while Drs. A, Z, and B were conversing the patients who were waiting to be seen were shooting disgruntled and hostile glances their way. One of them even went so far as to mutter words to the effect of “these people are heartless. Obviously they have never been sick before, or they would not chat while were waiting to be seen” (A, B and Z). The doctors overheard this, and after work the next day they began to ponder the hostility of the patients and proceeded to regale each other with anecdotes of hostile patients. Dr. A recalled the immediate past Saturday (24th July) where she had been on 9am-5pm duty at the out-patient department. She had arrived to her duty at 1 pm (she was on the wards before then). She recalled that she could feel the palpable hostility of the out-patients who were waiting for her – they had been waiting since before 9am, you see. She recalled that she passed she noticed that one of the patients was an old, frail gentleman at the back of the waiting queue. She asked the nurses to bring the man to the front of the queue because she wanted to see him.
The waiting patients were furious and loudly demanded of the nurses why the old man was being ‘jumped’ over them, especially since they arrived before him. One particularly irate man threatened to harm the nurses and/or disrupt the whole out-patient process if the old man was seen to before him. Her day continued amid the angry murmurs from the crowd. The other doctors had similar stories to share.
A simple misunderstanding or fundamental differences in opinion?
These little vignettes paint an interesting picture of the relationship between doctors and their patients in Sunyani and in Ghana as a whole.
Many house officers acknowledge that sometimes, they lack discretion. The three doctors previously discussed accepted that accosting Dr. Z in the middle of the waiting room at the out-patient department was not the best decision they made on the night of 24th July. Had they been more sensitive to their patient’s needs, they would have moved away: talking and laughing, even if only for a few minutes, in front of people who are sick, and waiting to see a doctor is not tactful, and even less so, when the people doing the talking and laughing are the doctors supposed to be attending them.
And yet, the doctors insist that allowances should be made for them. Dr. Z noted that on the night of the 24th, in addition to being sick3 she was tired that day – she had worked from 8:30 am to past 4pm, and yet had to report to the emergency room at 9pm. She insists that the three-odd minutes she spent chatting and laughing with her friends buoyed her spirits and relieved her stress somewhat. She pointed out that very few workers in the country had schedules as grueling as doctors4; she further noted that many of the people in the emergency, although sick, were healthier than her and had at least had more rest than her at that point in time.
Thus it is not just the patients who feel disgruntled; the doctors are resentful of patients too. However, an allowance does not seem to be made for their grievances. On many radio talk shows and forums callers phone in, abounding with stories of long waits and brusque doctors at the hospitals they frequent. The public is sympathetic to these people, because we all invariably have experienced such waits before. But no one calls to air the view of doctors because anyone who expresses empathy with the plight of doctors is excoriated. So the impasse continues, because no one is pepared to see the doctor as a human being – a particularly tired, sometimes sick human being who has as many pressures on them as the waiting patient.
In the words of Dr. A another point of contention between doctors and the public is that “the people have no real concept of an emergency and they expect us to run on a first-come, first-served basis; we simply cannot do that. An emergency takes precedence over all other forms of discomfort” (A). The three doctors further stressed that emergencies don’t always appear to be so. They gave a case-in-point:
Patient B arrives to the emergency room and sits with her quiescent baby in the corner. Patient A has been waiting with a wailing baby for close to three hours. The nurse sees patient B and rushes to call doctor. Doctor takes one look at Patient B and ushers her in ahead of all the other people in the queue. The patients are furious, but what they don’t realize is that patient A’s baby is a case of intusussception, which will keep even though the baby is clearly distressed. Patient B’s baby however, had encephalitis and needed immediate attention. In other words – baby B was a true emergency whereas baby A was not.
Perhaps one solution to this misunderstanding is education. But how does one go about convincing a woman with a baby clearly in distress that another woman’s baby has precedence, especially when the baby does not exhibit signs of distress? How does one go about convincing people that even if they arrive at 10am to see the doctor, the doctor won’t arrive until 1pm because she is busy seeing to the patients on the ward – who obviously need her more than they do, or that she will see the frail old man first, not because his case is more severe, but because waiting is more physically taxing for the aged than for the young? How does one convince people whose only vision of a doctor is a person who breezes in and out of a place that doctors’ work is more complex, more difficult and more time-consuming and more strenuous than they think?
Furthermore how does one convince doctors that they need to make more concessions? How can one convince a doctor that his/her working conditions are good when only one house officer is in charge of a ward – sometime one house officer is in charge of more than one ward? How can one convince a doctor that ward rounds must be done faster when they are already working as fast as they can without being negligent? How can one convince a doctor who has worked a 20-hour shift5 and is back for a 12-hour shift with no time in-between that they are insensitive? They insist they are going above and beyond the call of duty! How can one convince doctors who are not paid a salary for at least six months after they start working6 that concessions cannot be made for them? How can one convince a doctor who is sick and tired but at work because there is no replacement that a few minutes to relieve stress is unacceptable? How can one attempt to upbraid a doctor for not coming to attend to waiting patients until 1pm because she had been seeing to emergencies until then?
Education is paramount, but more than education is needed. More health personnel are needed, more sensitivity training is needed – both for the public and the medical professionals; more of a willingness to empathize with the other is needed; more infrastructure is needed….. it is indeed a herculean task to reconcile Ghanaian healthcare professionals with the population they serve. It is a political issue as well as a health issue. A population that demands its right to healthcare will not get it when they are uncaring about their health workers’ conditions of service, or when they refuse to acknowledge any of the grievances of a workforce burdened beyond comprehension – 0.15 doctors per 1000 people for crying out loud! The resolution of this impasse does not rest with the patients. It rests with doctors and with the government. Until government works to address doctors’ grievances and educate both doctors and the public on sensitivity, doctors will continue to leave the country, those that remain will have to deal with a worsening doctor-patient ratios, and doctors and patients will forever be disgruntled with each other.
A. Personal interview. July-Aug. 2010.
A,B,Z. Personal interview. July-Aug. 2010.
F. Personal interview. July-Aug. 2010.
"Ghanaian Health Stats." NationMaster.com. N.p., 2010. Web. 18 Oct. 2010.
Lambon, Justice Bukari. "Ghanaian Doctors and Strike Abuse." Editorial. Ghanaweb. N.p., 27 Aug.
2010. Web. 18 Oct. 2010. <http://www.ghanaweb.com/GhanaHomePage/NewsArchive/
1 A tertiary hospital is one where very complex medical procedures can be undertaken.
2Ghana is comprised of 10 regions, like the US is comprised of 50 states.
3 It turns out that she was quite sick – a few days later she was bedfast, because her symptoms worsened.
4 Dr. Z’s case is interesting. She was doing a surgery rotation at the time of these conversations. Surgery is infamous among doctors for being particularly physically taxing on doctors because of the physical strain of performing surgeries, and the many hours required for pre- and post-operative care. Additionally, she and only one other house officer were on the surgical ward, so their days were even more taxing than if there had been other house officers or residents. And she was sick too.
5 In Ghana house officers are on call 24/7. Anyone who works a full day and then spends a 12-hour shift(9pm to 9am) in the emergency room is expected to return to the ward for ward rounds right after the emergency room – no breaks.
6 Another Ghanaian idiosyncrasy: in addition to infamously infrequent pay, new doctors do not get paid for at least six months after they start working.