Saturday, June 6, 2015

The cost of negligence in the health-care sector in Bhutan

I know that there are many good doctors and health workers in Bhutan with excellent service records. I deeply respect and honor them for their whole-hearted dedication to the service of Bhutanese people. These people are highly professional in their approach to working with patients and take their responsibilities seriously and professionally. I have met many of them in my life. I would like to say that these individuals do not only make diagnosis and prescribe drugs, but they also seek to provide corrective emotional support which is an equally important component of a healing process for the patients. You may not believe me but simply talking to them makes you feel better because their words and tone carry a magical spell. But unfortunately, not everybody in the health-care sector has these qualities. Just as the good must be followed by evil, there are people in our hospitals and health facilities who do not seem fit well to be in a helping profession, because firstly, they don’t have the heart to own the problems of their patients and secondly, they don’t have the right attitude to deal with their clients. They seem to be doing their job just for the sake of earning a living. As a health-care provider, I feel all health professionals must be able to take ownership of their patients’ concerns and provide appropriate support in a professional manner. The following incidents would explain why I decided to write this article.

In 2010, my wife’s elder sister noticed a small lump in one of her thighs. As days passed by, she realized that the lump was growing bigger and she began to feel some pain. After the treatment at Sibsoo hospital did not show improvements, she decided to come to Thimphu to consult the medical specialist. In Thimphu, she was assessed by an orthopedic doctor who diagnosed that her lump was a benign tumor which could be removed by a minor surgery. . She was operated and the lump was removed. But in 2011, almost a year after the first surgery, even larger lump evolved just around the same place. This time, it kept growing vigorously bigger and she experienced unbearable pain. She could not even walk properly. By the time she came to Thimphu, the size of her lump was almost as huge as my one-year-old son’s head. We immediately rushed her to Thimphu hospital and went looking for the same doctor who operated her before. When we got inside his chamber, he blankly refused to own her as his patient when we explained to him what had happened. We gave him all the medical papers we had with us. He simply said, “I had removed the lump completely last year and now I don’t know anything about how did it come up again”. When I asked him what should we do next, he just advised us to see Dr. Lotay once. I don’t know why she was referred to the Urologist after all. Even then, we went looking for Dr. Lotay but the nurse at his chamber sent us back saying it was nothing to do with Dr. Lotay. We then went back to the Orthopedic doctor and this time, he asked us to consult Dr. Tashi Wangdi, the Oncologist. Dr. Tashi Wangdi was a very professional and nice doctor. He also wondered why the Orthopedic doctor referred his patient to him. When we showed him the patient’s MRI report, Dr. Tashi got shocked. He said if she gets late for the treatment, she might have to lose her leg. So, he remarked on the prescription “Please treat her if you can. Otherwise, refer her”. Dr. Tashi advised us that since the Orthopedic doctor had performed the surgery before, she was his patient and that he should be responsible for her further treatment. We once again returned to the Orthopedic doctor's chamber and only this time, he agreed to refer her to India. But all these things did not happen in a single day. We spent almost a month running up and down, from one doctor to another. It was quite frustrating at times. Finally, my sister-in-law was referred to Kolkata where the doctors diagnosed that her lump was a malignant tumor (cancer) and advised that she needs to be amputated as she was late for the treatment. After consulting her husband and other family-members, my sister-in-law had to make the hardest decision of her life: to lose one of her legs. She was amputated and when she was discharged, she was advised to return for a medical review after six months. But when she came back to Bhutan and reported this to her doctor, he refused to send her for the review saying it was not necessary. Then after a year or so, the cancerous tissues had regrown and this time, they had entered her body. She could not be saved although she was brought to Thimphu for treatment. She died a painful death in April 2012. I still feel if her doctor could have given her more attention, things would have been bit different for her.

In December 2009, my wife was in the hospital after the delivery of our youngest son through caesarian birth. There was this young woman a few beds next to my wife’s who had also given birth to a healthy baby-boy by caesarian. A few hours after the caesarian, the attendant of the woman complained to the nurse on duty that the woman was bleeding profusely. But the nurse just underestimated the seriousness of the situation and did not even bother to check the patient. She said “Who would not bleed during child delivery? Everybody would bleed for sometime” and she left. My wife told me that after sometime, the woman began to violently wince with pain as the effect of the anesthesia she was induced during the surgery gradually faded. She was losing a lot of blood. Only then the doctor was summoned. The doctor who had done caesarian on her immediately ordered that she be taken to ICU from where she never returned. She had died of excessive bleeding. The nurse who had ignored the complaint earlier had already finished her duty and she was not there when the patient she could have saved died due to her negligence.

Likewise, we have many incidents that could have been caused by mere negligence on the part of concerned health professionals. But the sad thing is that it seems we don’t have a proper avenue to seek justice. The hospital management board, which people mostly report to with complaints, often ends up defending the accused with so many technical explanations instead of launching an internal enquiry into the problem. Some victims have attempted to do this before but nobody has ever succeeded in their fight for justice so far. The most appropriate option will be to drag the accused to court but can we really do that in Bhutan? Till date, nobody has ever dared to do this simply because it’s a very hectic and costly process. It seems as of now, many victims are stuck in a deadlock. Until a more vibrant system falls in place to clean up the entire sector, we must survive at the mercy of those so-called very professional and kind-hearted health workers who are not yet influenced by evil minds.


  1. sorry for your loss. i feel u. When the lump was excised first was it not sent for histopathological examination(HPE)?? What was the diagnosis ??? if HPE was sent then surely we would have found out what the first lump was. Also incase of the recurrent lump was a tissue biopsy not done?? what was the final diagnosis ???soft tissue sarcoma..

  2. Dear Amrith,
    My deep condolences for your great loss. Without going through her records it would be very inappropriate to make any concrete comments. However as a concerned health professional I would like to explain to you that there are many benign tumors which has the propensity to transform into malignant form(more aggressive). Eventhough it was benign initially and removed surgically, there is always associated risk that some part may be left out as it is very difficult to see during operation especially if the tumor margins are irregular and not well defined. However the operating surgeon must make sure to closely follow up such patients. I am sure she must have been told to come for follow up, if not then there was negligence.

    Secondly if your version of story is true, I dont see any reason why that orthopedic surgeon refused to see her during second visit. It might be that tumor this time was not related to his subject. If it was related to general surgery, refering to dr lotay was never a mistake. Dr lotay is general surgeon with superspeciality in urology. Doesnt mean he cant handle surgical cases. He can very well do that. You havent mentioned her final diagnosis anyway. If the case was related to orthopedics(case of abnormal muscles, bones and joints) there is no reason for him to refuse seeing her.

    Lastly, with regard to follow up to kolkatta, I think there are many factors to consider such as overall prognosis, cost, patients general condition and so on. For instance if patient's survival is not going to change then the patient should be given palliative care only. Doctors in india will always tell patient to come for follow up because they dont take cost into account. They either think our government is paying or patient can afford to pay. Usually the follow expenses are borne by patient party if I am not mistaken.

    With regard to womans death, if what you wrote is true it need appropriate investigation. Maternal care shoud be given utmost importance at any circumstances.

    Whatever it is the overall healthcare in Bhutan is at very primitive stage. We boast of providing free services but we dont have even basic facilities compared to other countries. Most patient die while getting delayed for referral to india or abroad. Only VIPs are fast tracked. So to improve services we need to change the system, need to recruit competent doctors and health professionals, doctors need to be well updated in knowledge ans skills, facilities need to be improved, advanced private hospitals need to come up for those who can afford. Patient need to be compliant. So before making any conclusion let us think where we went wrong.

  3. Hi la,

    Thank you so much for going through this article and leaving a comment. What you have explained makes a lot of sense la. But my sister-in-law was not called for any follow up. The final diagnosis in India was that it was cancer and she was amputated just below the hip as it was about to enter the body. I have no technical knowledge of medical science and Hence, I don't know what really went wrong... But I just felt if her doctor in Bhutan could have been more concerned about her problem, she might have been able to survive for some more years. But once again, I am not generalizing this to all health professionals. I have met so many others who have been excellent. It was just my general concern la.

  4. Good insight, I am a health worker and I do share your sentiments. Well our system can only improve if such feedback are given on a regular basis and quite vigorously. We have Bhutan Medical and Health Council which is a regulatory body for all health workers. Please visit the website, there is a complaint form to lodge complaint against health worker and hospitals. We must understand, only through complaints and feedback we can improve the system. Alternative once could also lodge complaints to health administrators and the Hon'ble health minister. I encourage all our people to complain to improve the system.

  5. Hi Karma Sir, thanks a lot for this valuable advice and seconding my views. It's just because of one or two individuals the system is paying the prize. Otherwise, I think our people are doing their job pretty well.