Monday, February 21, 2011

Patient safety

Our first speaker, Uma Nambiar, noted that clinical engineers have to make their value obvious in the medical hierarchy. She suggested that one way to do this would be to make clinical engineering patient oriented, specifically to assert that clinical engineering is about patient safety. Another speaker mused about how the Indian clinical engineering profession might get there, given that he thought Indians had a cultural problem with safety, using the way Indians drive as an example. This gave me pause for thought on the basis of what I had already concluded about Indian driving. There are two ways to approach safety. One is to prevent accidents happening, and the second is to deal with the consequences. Our second speaker mentioned people not using safety belts and cycle helmets – that's minimising the consequences. There is some evidence that minimising consequences actually makes people drive less carefully as they begin to believe they will not get hurt. My view is that it's not a cultural thing so much as an economic thing – safety features in cars, good maintenance of buses, proper replacement of tyres, rebuilding of roads all prevent accidents but don't happen unless they can be afforded. In terms of culture, if anything it goes the other way – Indians, possibly because of their culture, are, in my view, better drivers than people in the UK are.

In terms of patient safety that made me think that there is probably an Indian way of doing patient safety. It will be different from the western way, it will have different strengths and different weaknesses, but it will work better in India becvuase it will be specifically Indian. Western patient safety is based on two principles which are not encessarily the most effective. The first is the highly materialistic Judaeo-Christian life model of western culture in which everything that can be done must be done regardless of the cost in money or the patient's dignity. The second is that a lot of safety features, devices and practices are not about patient safety so much as about doctor safety – there for the purpose of vitiating litigation. It may even work against patient safety in the long run. I would not like to see either of those features replicated in other countries.


My first impressions of India are of a country that I really enjoy and that will continue to grow on me. I've been here two days and seen only urban India in Delhi and Pune. Many things strike me; it's not as hot as I expected – I came at the right time of year. The food has been good, and I have found so far, as I expected, that Indian food in India is very different from Indian food in the UK. All the Indian people I have met so far speak to each other in Hindi, and to us in English. All of the big advertisements round about are in English. I have found some things quite disconcerting. I haven't been bothered about the juxtaposition of poverty and wealth; that is so well known already that direct exposure to it is not a surprise. The way in which streets and spaces are organised was a bit disconcerting but I am getting used to it. I can't quite get my head round the sudden appearance of a shack or a sales pitch in the middle of rubble.

I have had just a surface view of India so far – I have seen a small group of students, professionals and intellectuals. I have mixed with hotel and restaurant staff, and I have seen life on the streets – the driving, the way people walk, the selling of wares on small scales in Hindi and large scales in English.

I feel a clear sense of Indian identity very present to me. I have not been able to define it but there seems to be something very specific and Indian about the way everything is – the way they dress, particularly the colours, the way they talk, the way children behave, the language they use in advertisements and newspapers and on television, their sense of their own history, their sense of themselves, a certain way of mocking their own weaknesses. The history was also very present and real to me, in the tourist places I visited. At Qutb Minar I felt I could see how it would have been when it was built, how the whole place would have been when alive and functioning. At India Gate I felt a sense of profoundness at the guarding of the memory of those who have fallen in India's wars. The memorial was so like others in Britain, France, Germany, the USA, and yet it had an Indian stamp. At best I can express it as a certain sense of warmth and centredness about the people I see all around me. It made me wonder about the relationship between India and the force of globalisation. It seems as if cultural globalisation has just bounced off the surface. The McDonalds, the Costas and the Dominos Pizzas are there but they haven't wormed themselves into the Indian identity the way they have done in some countries. So there is a very different relationship here, it seems, one in which the Indian identity is maintained and vibrant. Some things are the same all around the world. People in India want to get rich and want to have a good time. They are attracted towards certain western products, and lifestyle – I see it in the apartments, the clothing, the cars, the lifestyle that is offered on the big advertisements, but I see no danger that it will ever suck their soul away.

India, driving and order

I really like India. Our schedule left us time to sightsee in Delhi on Saturday afternoon, and in Pune on Sunday morning. In Delhi we saw the Lotus Temple, the Qutab Minar and the India Gate. In Pune we went for a long drive to a monument and found the road to get there was shut. But we spent a lot of time driving, and that was really fun. The first thing that strikes the English ear is that they use their horns a lot. The second thing is that they need to because lane discipline is an alien concept here. To the English sensitivity the whole thing seems to be entirely chaotic, and possibly quite intimidating, but after looking for a bit longer, I realised that it is very definitely order, just not as we know it.

I've only experienced urban driving in India so I don't know what it's like on the motorways. But urban driving in India is alert, purposeful and highly collaborative. They are better drivers than most UK drivers. Not just because they have to be; I think there's an element of choice about it too. First of all, to describe it.

They drive very close together, both side to side and front and back, much closer than would be tolerated in England. If there is a gap they go into it, regardless of how narrow it is or whether it is between lanes. They drive on the wrong side of the road, even when traffic is coming directly towards them; by the time it gets there they have melted back on to the right side of the road. If they want to pull out into the traffic, either from the roadside, or a minor road, they do. The oncoming traffic flows around them. They hoot for information, not out of vexation. They hoot to let people know they are there. Auto rickshaws and trucks often have painted on their back “Please hoot”. I've never yet heard someone hoot in anger, despite all the manoeuvring and proximity. In Britain we use our horns to tell people they have annoyed us, though my British readers might be interested to know that the official meaning of a horn sounding, as in the Highway Code, is “I am here”, exactly as they use it in India. That was the first thing I really noticed, that the sounding of horns was not an argument as it would be in the UK, but more like a constant conversation. When they drive into a space other people may hoot at them, but it's to let them know that they are very close. They are often driving at 30 mph about 3 inches apart, they are constantly manoeuvring to avoid things ahead of them, and things behind are constantly manoeuvring to avoid them.

So they have to be alert to what is going on around them all the time, they have to anticipate things happening from any direction, they have to be purposeful to make progress, and they have to drive with restraint in order to let all the other drivers around them make progress as well. And they have to be capable of driving inches apart from everything else on the road. They do so very successfully, and I don't think many British drivers would do nearly so well.

Possibly one of the reasons is the different forms of transport. There are cars buses and lorries as in England, there are more motorbikes and scooters, and more bicycles. And of course pedestrians. There are also bicycle rickshaws usually pulling large and heavy loads very slowly, and auto rickshaws, which are little more than 3 wheel scooters. So there's a combination of small and slow vehicles for everyone to negotiate.

The second reason is that very few people are concerned to get to their destination as quickly as possible. In the UK we tend to regard everyone else on the road as an encumbrance. In India they seem to recognise that everybody is trying to get somewhere, and they aren't the most important person on the road. There may be a cultural element in there somewhere, something to do with British culture being very individualistic, whereas Indians are by and large more attuned to collective responsibilities. Although we don't think of it as such, road driving is a highly collaborative activity. Watching traffic at a busy roundabout, say, you can see how drivers co-operate with each other to get everybody through in an apparently random but reasonably fair way. It may also be noticeable that the driver who tries to jump the queue, of whom we have many in the UK, slows a lot of other people down. Individualism can actually prevent people getting what they want in the most effective and efficient way. In a way, seeing how others drive is most influential as a way of reflecting back on how we drive.

The final factor, I think, is about awareness. I have no idea about conscious awareness in Indian drivers. It is certainly high in practice as the lack of accidents in Indian driving. In UK drivers it is lamentable for the most part. Whatever we're taught in driving lessons we forget as soon as we have passed the test; I have met very few British drivers who feel any need to actually concentrate on their driving when they are driving. I get the impression many think that would be a waste of time they could much better use chatting to their passenger, talking on their mobile, whether legal or not, listening to the radio or just day dreaming.

But to return to my original theme, that of order, I see in the Indian situation something that in British eyes would be simply chaos, but which is in fact very well ordered behaviour by thousands of people all in a very small space. It is, in fact, ordering of the highest quality, just different to the we do it in Britain. That in itself raises different questions about how we perceive order. There are very clear and powerful cultural influences on what counts as ordered and as disordered in different situations.