b - it does not take into account, or even mention, the traditions and customs of the local (dominant)Arabic population in what is acceptable and what is not, instead, reference is made to ‘multicultural patient population’, and even no attempt is made to illegalize what is offensive or unacceptable to a patient’s culture. I do not think that it will be acceptable for any culture that a female doctor shall attend duty wearing tight stretch pants under a short lab coat!
By now, several people have entered the fray and the responses are coming thick and fast. A dress code committee is suggested but one of the commentators feels that we could be more measured and allow doctors to use their own judgement in matters of dress:
We are dealing with mature educated doctors who are culturally competent most of the time.
Such an opinion is apparently completely unacceptable and merits the response:
The fact that we are dealing with mature doctors is not a justification that we allow them to be dressed the way they like. I have seen myself dresses which are off the beaten track and need to be checked and, irrespectively, we have to have that kind of regulation in place, before we hear and read criticism from the community and the media.
Criticism from the media is always a worry, in particular from the Arab press who are often highly critical of the hospital, especially when westerners are perceived not to be conforming to Arab ways such as dressing “off the beaten track” - potentially a major concern. However our measured correspondent has an answer - we must engage stakeholders, form a focus group, brainstorm the issue and most of all, we must be scientific about this:
Although you disagree with everything I said (you are entitled to your personal opinion) I agree with you though on one comment which relates to culture and public opinion and the image of our corporation. Don’t forget that we deal here with a cohort of staff from multicultural backgrounds and proudly we respect cultural differences as long as decency is the rule. Instead of keep talking about it on the net or, as you said, in the media (although no one has seen that) ... we need a committee from stakeholders ... from both genders and from different backgrounds, starting with a focus group to brainstorm this issue and agree or disagree on a professional basis Then higher authority will approve a detailed policy and get committed to provide the needed resources and each team will be responsible to implement and monitor feedback and remediate. That’s how we in Medical Education function USING A SCIENCE BASED APPROACH without intimidation or threats in a supportive professional environment.
You will note that all this will happen in a supportive non-threatening environment, but this is not good enough for the lawyers, who respond:
I think we are now coming to an agreement that it is necessary to have a corporate dress code for all classes of physicians (Albeit some innuendos in your message!). All organized hospitals have such a policy.
He also makes the legal point that without a policy we can’t punish anyone and drifts into Latin in case anyone has missed his point:
Please note that we may not oblige an employee to a certain type of dress, or hold him/her accountable for violation unless we have in place a bylaw or policy prescribing the requirements for such dress code, ‘no punishment except in accordance with the law’ (nulla poena sine lege).
It is still running with multiple correspondents and diverse ideas. A query is raised about wearing a thobe and ghutra underneath the white coat and finally Lionel can hold back no longer. He points out that the white coats are filthy, are worn outside in the dusty desert and maybe infection control might play a part in this debate. No one is interested. We simply revert to concerns over young women wearing tight trousers. Still, following the emails brightens up my day. I wonder what they think of the hoots of laughter emanating from my office.
9. Ramadan
We’ve had a bit of a false start. We were invited to Break Fast, known as Iftar, with some Muslim friends on Tuesday evening. But then the night before, it was all changed. Ramadan would start on the Wednesday and why? Because the moon committee had not sighted the new crescent moon. Now we Brits know about such things simply because we are aware of tides from an early age and tides are governed by the moon. Tide tables are published at least a year in advance and are remarkably accurate, so why can’t these desert dwellers who live in a scientific age, predict the first day of Ramadan?
Admittedly we couldn’t see the new moon either, but then we aren’t the experts. Apparently one year there was a disagreement between two adjacent Arab nations and the timing of Ramadan was different as a consequence. We ask colleagues when Ramadan will start and these highly educated doctors start consulting almanacs, stoking their beards and discussing the response. Lionel witnesses three of his Arab colleagues talking for half an hour about the likely timing of Eid al Fitr, which is the holiday following Ramadan. A few days public holiday are granted but no one can predict how many and we have to wait for the Emiri decree, which is conveniently announced the day before.
An added complication is that this is extra holiday and not part of the annual leave allowance. How wonderful, you may think, except that if you take leave either side of Eid then the Eid days count as annual leave too! I could make a facetious comment about courtiers made of cards painting roses red because the Red Queen is due, except I’ve been given a beautiful long-stemmed rose that has been meticulously dyed so that all the petals are different colours of the rainbow, not to mention the twenty-four carat gold plated rose which was also a gift. We really are living through the looking glass.
Everyone fasts from just before the sunrise call to prayer, currently at about 3.30am, until Iftar at 6.30pm. They eat and drink nothing, not even a glass of water, during these hours. Work time has changed to 8am to 1pm for Muslims only. Any public display of food or drink consumption is frowned upon and until recently was an offence punishable by law. Lionel and I join in and fast on the first day, while quietly drinking water behind closed doors. I am determinedly carrying on throughout the holy month except I still drink water during the day and indulge in a hearty breakfast when I get up, not in the middle of the night.
Children as young as seven go into training, gradually increasing their hours of fasting and by the age of ten they are expected to fast like adults. The whole family will be awake to share the 3am meal (Suhoor). Of course a lot of sleeping is done in shifts, early morning and afternoon. Feasting goes on through the night and extravagant Suhoor buffets in the large hotels continue from 9pm until 2am the next morning. While Lionel and I are wasting away (well a few pounds lighter anyway), the radio gives tips on how not to gain weight in Ramadan, but though we listen for it no one tells us when the shops will be open.
Supermarkets are usually open during the day but opening hours of everywhere else are completely random with no indication of opening times on their doors. We presume the malls are buzzing into the early hours but we are disinclined to venture out then, not least because we have to do a full day’s work the next day. There is no ambiguity over the sale of alcohol: it is expressly forbidden during Ramadan.
The first day of Ramadan sees an increase in accidents. Apart from numerous bumps and collisions, someone drives his Land Cruiser off the road ploughing into three workers who are resting on the grass verge and killing all three, while two labourers fall off high-rise buildings on which they are working. To a medic, it does beg the question as to whether the perpetrators of these horrific accidents were hypoglycaemic at the time. Other health risks include an increasing incidence of kidney stones during Ramadan, due to the intense dehydration inflicted on the faithful.
Two weeks in and the number of violent deaths admitted via the hospital has risen to twenty-two. The chief executive of one of the hospitals, a feisty African-American woman, remarked, “It’s becoming like district Chicago round here!”
Stabbings and shootings are not unusual. In spite of this being a holy month, fe
asting and fights carry on into the night, out in the desert mainly, among opposing tribes. Even the sophisticated, western-educated Arabs are tribal and our urbane Arab colleagues talk about the poetry wars that have lasted several generations. A cardiologist and a thoracic surgeon each come from notable families who have been at loggerheads for generations in a dispute as to who writes the best poetry. The two doctors often clash over clinical matters but it is their own poetry which really fuels enmity between them. And they are deadly serious.
Muslims may work from 8am to 1pm but we infidels have to put in the usual hours. It works quite well in practice, with meetings in the morning and catch-up time in the afternoon. Clinical staff might work slightly reduced hours but the patients keep coming, so the work goes on. It is tough for those operating or working in the Emergency Department, where there is no respite and no food or drink. The newspapers give helpful tips on how to deal with Ramadan, including reminders of the rules, which include:
No sexual intercourse with one’s spouse.
No intentional emission of sperm unless asleep (followed by a remark about the perils of masturbation.)
Menstrual blood automatically breaks fast (but you have to make up the fast day when the period is over).
No swallowing blood from a nose bleed or it breaks fast.
No donating blood unless in dire emergency.
There are a few more seemingly incongruous rules such as not being allowed to induce vomiting in oneself. Unless you are at Roman feast and are handed a feather, or are a mistaken bulimic trying to vomit on an empty stomach, why would you? All the above can be done during the dark, except presumably intercourse with anyone other than one’s spouse is still prohibited and masturbation is apparently still not acceptable, even by moonlight.
The month is designated as holy and alms-giving is encouraged. Good deeds are performed, such as taking Iftar to elderly people and breaking fast with them. Customer loyalty points can be traded in and given to charity and there are messages of generosity and tales of beneficence daily in the newspapers. A particularly charming story is that of Garangao, which is a children’s tradition practised on the fourteenth day of Ramadan. The children dress up in traditional costume and sing a traditional song while onlookers ply them with nuts and sweets.
Alternatively the children might knock on doors and sing to the householder, who rewards them with goodies. One of my (Muslim, but non-local) colleagues suggested inviting the hospital teams to Iftar in one of the hotels as a way of thanking them for their efforts in an important project. I thought it was a great idea and consulted a senior Qatari, who agreed with the premise but advised, “The Qataris will not come as it is a time for families in this part of the Gulf.”
Meanwhile we have taken to gazing at the moon in order to gauge progress. It is definitely starting to wane and the prospect of eating during daylight and our forthcoming holiday becomes increasingly tantalising. Ramadan kareem (Blessed Ramadan) to all.
10. Building bridges
The Arabs want to embrace western medicine. They understand it in terms of the science and technical advances but in their own milieu they tend to revert to cultural norms. So although there is ostensibly a willingness to embrace teamwork across the professions, in practice the hospitals are still very hierarchical. This perpetuates a blame culture where mistakes are hidden, complaints are ignored and patient care is inevitably compromised. Not that we are perfect in the western world: we too have a long way to go.
One of the problems in HMC had been a disconnection between administration in the corporate offices and the clinical staff in the hospitals. Because of my strong clinical background I am able to build bridges between the two. The problem is how to get the messages across those bridges. I decide that we need a series of conferences or workshops where we can share ideas, discuss international research and together improve the systems underpinning patient care in our hospitals.
My slowly slowly, shwai shwai approach is working. The groundwork in reaching out to the hospitals across the country has been worthwhile. In terms of getting the doctors on side, I am pushing against an open door.
The corporate view is to engage some experts from out of town, somewhere convenient like London or New York. We have already done some work with the Harvard Business School, who have been fantastic, but only a small number of senior clinicians could be included in such an approach. My view is that we need to tap into the considerable expertise of our own doctors.
Moreover, I am not going to be there forever and I want to overcome the passive resistance and that learned helplessness that we all encounter. I want to cede control to the locals, to give them self-belief, to stop the constant blaming of the administration and encourage autonomy with inclusivity. Less of, “I’m the doctor and I know best,” and more of, “We are a team. Let’s work together to do the best for our patient.”
So we invite every single consultant in the country to attend one of a series of one-day workshops in Doha. I will have the opportunity to meet each one individually, and to reinforce how much they are valued by me and the organisation. They will all have the opportunity to air their views.
It is a gamble and a risk. We wonder if they’ll turn up: they do. We even have to put on extra days to accommodate them all. By giving everyone large easy-to-read name badges, I am also able to pretend that I know all their names, all six hundred of them.
I arrive after the usual battle through the traffic, draw up at the grand entrance and simply get out of the car, leaving my key in the ignition. I am greeted by, “Good morning ma’am” as I walk into the hotel. My car is valet parked and retrieved for me at the end of the day. When I arrive at the workshop venue, my completely veiled member of staff embraces me warmly, comments approvingly on my clothes, then presents me with a bunch of fresh flowers.
There are fifty senior doctors attending each day and I wander round the tables greeting people and chatting. Everyone is very warm and they all want to talk.
Discussion between lectures is vigorous and there are some great ideas around leadership and clinical practice. In the interests of inclusivity and breaking down barriers, I have invited the corporation’s senior lawyer to one of the sessions, thinking that it will give him some insight into our medical values. We are doing much work currently on patient safety and on promoting a ‘No Blame’ culture. Our Sudanese lawyer with his British degrees is a confrontational man, as evidenced by his correspondence on dress code.
When he expresses concern that there is no rigorous punishment for doctors who have made mistakes, the response from one of the Qatari surgeons is voluble and emphatic in the extreme. With thobe and ghutra flying, he is on his feet shouting at the lawyer, who returns in kind.
“What does he know about medicine? He would put us all in jail for a simple mistake,” pronounces the surgeon.
“Doctors think they are gods. He only operates for money like a typical plastic surgeon. The country needs lawyers like me to keep these doctors under control!” comes the swift riposte.
The insults are explicit. At one point the surgeon asks me, “Why is this man here?” to which I point out “He is my guest.”
The exchange lasts several minutes before I am able, as chair, to restore order. Needless to say, the lawyer doesn’t last the day and he is subsequently very peeved that I gave him no right of reply to the accusations against him. For good reason - it would have turned a skirmish into a full-blown battle, which none of us needed.
The gossip has already elevated the heated exchange to a stand-up fight. I am still not sure whether my reputation is enhanced or hindered by the incident.
If a session is in danger of over-running then I check with one of the senior Arabs to ensure that we are not running into prayer time. One day, the men decide to stay in the lecture room for prayers. One stands at the front with several others facing him and starts pro
ceedings. They are at a slight angle to the geometry of the room so presumably someone knows the direction of Mecca. I also assume that they all kneel and touch the floor with their foreheads but I slip away quietly before they reach that stage.
Imagine such a scene at a UK conference. Here in Qatar, it is assumed everyone is religious and they all believe in God. These highly educated Arabs have no problem with the concept of evolution and have reconciled God and science in their minds and in their culture.
Occasionally I have interrupted someone at prayer in their office. Devotion is such a part of daily life that no one is surprised except us westerners. Many men display an area of thickened skin, a callus, on their foreheads from repeatedly touching the ground with their head when at prayer. A local who works in an adjacent department popped into my office recently with gifts from Mecca. He had just returned from pilgrimage and presented me with Arabian dates and holy water in a tacky plastic urn. He instructed me to drink it and pray. I was grateful and very touched, but can you imagine such a scenario at home? Not for the first time, I find myself musing that we are living in a modern world with a medieval mindset: but then the date here is 1450, so perhaps that makes sense.
The Emir publicly prayed for rain last week and this week we had a deluge. Since drainage is not a strong suit out here, the roads are consequently flooded and the accident rate is even higher than usual. No doubt the prayers are part of a long-standing ritual but I am sure many will believe that the rain was due to the Royal intervention.
Still, through my worries, the unexpected squabbles, and expected prayers, several people compliment me on the workshops, usually along the lines of, “I didn’t want to come, but it has been good.”
One neonatologist beckons me over to her table.
“I prayed to Allah that this would not be a waste of my time,” she said. “Eight precious hours away from my patients is too much.”
800 Days in Doha Page 8
