Article Review “Etnografi Ruang Instalasi Gawat Darurat (IGD): Relasi Dokter dan Pasien di Rumah Sakit Umum Kota Makassar”

Tulisan review untuk Ujian Akhir Semester (UAS) Membaca Etnografi. Artikel: https://journal.unhas.ac.id/index.php/etnosia/article/view/5154

The hospital plays an important role in today’s society. It ensures the health of the overall society. Therefore, the most important person in the hospital, the doctors, have a duty to build a good relationship with patients to ensure the health of their patients. This article is oriented towards the relationship between doctors and patients. The author argues (though not explicitly), in the abstract section, that there is an imbalance between doctors and patients leading to miscommunication, differences in treatment, and family/kinship prioritization at a certain hospital in Makassar. This was shown by the sentence:

This study shows that (1) the doctors did not pay attention to and run the SOP IGD of General Hospital so that there was a miscommunication, (2) health insurance patients and the general got different treatment in medical treatment, (3) kinship network was very influential in the medical action given by the doctor to his patient (p. 250).

The methods that the author uses to write this article are also provided in the abstract section. The author mentions that they are using qualitative descriptive studies with in-depth interviews with doctors and patients and observations as their method to conduct this study. To be more precise, the author created an entire section dedicated to explaining the methods used in this article (p. 252–254).

Entering the introduction section, the authors explained the condition of the hospital where the study was conducted, especially the emergency room (IGD) of that particular hospital (the name was disguised). The authors explained the general conditions of doctors-patients relation. Traditionally, the doctors-patient relations have an imbalance (paternalistic) with doctors having higher grounds because of their medical background.

However, even though doctors have higher grounds, the authors explained how things should not be like that. The authors describe that doctors have a duty besides healing patients. Doctors are still required to build good relations with patients. The main highlight in this particular section is that doctors are required to take into account the social and cultural backgrounds of their patients. However, as the article suggests, in reality, doctors often make a one-sided decision. Now, this makes sense remembering that doctors do have higher grounds, but higher grounds do not equal “authoritarian” rights. Then, a question arises about the condition of doctors-patients relations at a particular hospital in Makassar: does doctors-patients relations inside the hospital at Makassar is a one-sided relationship with doctors holding the higher grounds? Even though the authors do not explicitly mention the question they want to answer, the whole body of the introduction sections leads to that question.

The main argument of this article is also not stated explicitly in the introduction section. However, looking at the last paragraph of this section, the sentence “Artikel ini akan menjelaskan suatu realita yang terjadi dirumah sakit, bukan hanya mengenai komunikasi dan pelayanan, namun juga perlakuan yang didapatkan oleh pasien selama melakukan perawatan di IGD RSU X dengan mengacu pada perspektif relasi” (p. 252) could indicate the main argument the authors trying to prove. Supported by the explanation in the introduction section, with this sentence, the authors are trying to say that there is an imbalance in relations between doctors and patients and it created a difference in communication, service, and treatment inside the RSU X emergency room. In other words, borrowing the terms from the conclusion section, the doctor-patient relationship at RSU X emergency room is a passive one with doctors ``dominating” in that relationship. Hence, it created a difference in terms of communication, service, and treatment patients receive.

Onto the main part of the article (the analysis), the authors provided evidence, mostly from their interviews with the patients, that indicates the imbalance in doctors-patients relations. The main part is divided into some parts. First, the authors explained the professional ethics of doctors. The evidence provided by the authors is a statement by a certain doctor. His statement is:

“Kami dari pihak dokter rumah sakit khususnya di IGD akan memberikanpelayanan pemeriksaan semaksimal mungkin karena itu memang tugas kami, tanpa membedakan pasien dari segi apapun, saya sendiri selalu melakukan komunikasi. Hal ini saya anggap mampu membuat pasien percaya dan menyerahkan semua proses pemeriksaan untuk mendiagnosa penyakit kepada kami” (Rio, 16 Juni 2018) (p. 255).

The authors are trying to bring some perspectives with this. Even though they try to say that imbalance exists, the authors first bring readers to another perspective for a minute — which is something to be appreciated. However, after that, the authors bring another piece of evidence. This time, the evidence is the one that proves the author’s main argument.

“Kita disini memang statusnya sama semua sebagai pasien tapi ada namanya pasien VIP dan ada pasien biasa. Kalau pasien VIP jelas mi dokternya cepat tangani karena langsung membayar dia. Coba kalau kita pasien biasa pasti agak lama ditangani karena kita tidak langsung membayar. Jadi itu namanya kalau dokter dibilang tidak bedakan pasiennya memangbenar. Tapi tidak semua tawwa dokter begitu sifatnya karena ada ji juga yang kerja sepenuh hati. Sebetulnya kalau saya bukan dokternya yang salah karena diakan juga tidak tahu ini pasien VIP atau bukan kan dia dikasi tahu ji juga sama pihak administrasinya, baru kalau pasien begitu pasti sering di cek kondisinya.” (Munawir, 28 Desember 2018) (p. 255).

This statement provided by one of the patients at RSU X, proves there are imbalances between doctors and patients. Because doctors have more “power” or higher grounds at doctors-patient relations, they could “make some adjustments” with their services. With this statement, doctors are more likely to prioritize patients with more money or the ones that pay right away. Doctors could do this because of power relations between them and the patients. If doctors and patients are equal, doctors can’t prioritize someone just because they have more money.

This continued onto the next parts that explain the different treatments between patients with health care and the patients without health care. The evidence provided by the authors comes from two persons, the patients with BPJS and patients without BPJS. The patients with BPJS mentioned that:

“Saya disini dirawat pake BPJS waktu pertama ka dibawa masuk ke IGD terlalu bertele-tele sekali pengurusannya, apalagi saya BPJS ku kelas tiga. Baru dokterya juga lama sekali datang untuk tangani ka” (MU, 28 desember 2018) (p. 257)

This answer proves that doctors are prioritizing patients without health care because they have to pay right away. This could only be done if there is an imbalance between doctors and patients, thus proving the main argument provided in the introduction section.

To make sure if this is the case, the authors provided an answer as evidence by patients without BPJS:

“Sebenarnya saya punya BPJS cuma saya tidak pake karena kemarin ada Om ku masuk juga disini tapi lama sekali baru ditangani. Makanya waktu kemarin saya masuk di IGD statusku sebagai pasien umum.Karena saya piker kalau umum cepat ditangani.Lagian juga bapakku bilang pake umum saja karena luka ku tidak parahji. Tapi memang betul kalau umum cepat ki ditangani terus dokternya juga perhatian sering na tanya kondisiku” (Arsan, 28 Desember 2018) (p. 257).

This person admits that without BPJS he is receiving better treatment compared to the ones with BPJS. This makes the previous point more apparent. In addition, this statement proves the main argument because, as stated before, this could only happen if there is an imbalance between doctors and patients.

Next, the authors examine how kinship relationship influences the difference in treatment patients’ receive. The article shows that kinship relationship also influences the difference in treatment patients’ receive in an emergency room in RSU X. Another explanation from one of the patients is provided as evidence:

“Selama saya dirawat disini bagus pelayanan yang saya dapat, darah gampang saya dapat, dokter sama perawat juga baik sama saya, waktu saya datang juga cepat juga ditangani, baru cepat juga dapat kamar rawat saya disini baru satu hari tadi pagi saya masuk di IGD untung ada keluargaku kerja disini jadi dia tadi datang tanya dokter supaya cepat ka dibantu, Alhamdulillah kasian jadi tidak lama ka menunggu” (SA, 23 Maret 2018) (p. 258).

Those who have kinship relations with the hospital staff — either the doctors or administrative staff — are more likely to receive special treatment. This point further proves the one-sided relations between doctors and patients. Again, this could only happen because doctors obtain higher grounds in this relationship.

The next section dissects the communication aspect of doctors-patients relations. The authors start by explaining how doctors and patients ought to be equal to avoid an unwanted outcome. However, reality shows that things are not like that. The authors provided previous research by Dianne (2007) (p. 260) that explained why doctors and patients are not yet equal in their relationship. She suggests that doctors think that good doctors are the ones with competent diagnosis skills, while patients think that good doctors are the ones with listening skills, indicating an imbalance of medical knowledge.

The difference in medical knowledge contributes to the imbalance of doctor-patient relations. The authors cited Jay Katz’s works (p. 260) that revealed that because of their sickness, patients are dependent on doctors — because of their “magical skills” in healing patients. Thus, leaving all decisions to the doctors. This gave rise to the feeling of being abandoned by the doctors inside the patient’s heads. The authors provided yet another statement by one of the patients as grounds

“Sudah 2 hari saya di IGD ini, mamaku (60 tahun) yang bawaka ke rumah sakit. Keluhanku datang kesini karena muntah darah, selama disinika tidak ada obat dikasihkanka tapi di infus jaka saja. Sudah 2 kali maka di periksa sama dokter ini seharian dari kemarin malam dengan tadi siang” (Aliyah, 12 Mei 2018) (p. 261).

While this miscommunication does not really correlate with the main argument of the article, the thing that gave rise to this phenomenon — a disparity in medical knowledge that contributes to the imbalance in doctors-patient relations — does correlate.

The last section is actually contradictory to the main argument. The last section explained how sometimes there are doctors that are willing to back down. The example provided by the authors is another narrative from patients

“Saya masuk ke IGD karena muntah darah dan tidak sadarkan diri tapi memang saya dibawah pengaruh alkohol. Saya pake jaminna BPJS tapi tidak bisa dipake karena hasil diagnosa dokter saya mabuk tapi setelah dikomunikasikan dengan dokter akhirnya dokter ganti hasil diagnose jadi sakit batuk dan muntah darah akhirnya saya bisa pake kembali kartu BPJS untuk bayar rumah sakit” (Maruf, 15 Mei 2018) (p. 265)

and from doctors

“…Kalau masalah itu pak, begini saja saya akan ubah hasil diagnosanya pasien, dikertas diagonosanya nanti akan saya masukkan bahwa pasien sakit karena batuk dan muntah darah. Sebenarnya pasien ini memang sakit seperti itu hanya saja ketika dilakukan pemeriksaan kadar alkohol didalam tubuhnya sangat tinggi itulah mengapa hasil yang keluar seperti itu. Saran saya pak kalau anak bapak nantinya sudah merasa agak baikan, bapak bawa lagi ke sini karena sepertinya lambung anak bapak bermasalah dan harus segera dioperasi” (Abdi, 18 Mei 2018) (p. 265).

that shows how doctors sometimes drop off from their high grounds to give service to the patients. This shows that the articles bring some perspectives to the issue.

Before I elaborate on what the authors wrote in the conclusion section, I want to dive into the fallacies the authors make in this article. The fallacies are related to the concepts of logos, ethos, and pathos. While I do explain how the evidence provided supports the author’s argument, by no means do I think all of them are sufficient enough.

For instance, the authors said that the relations between doctors and patients are not paternalistic anymore, but contractual (p. 254). However, the authors do not provide sufficient grounds to support this statement. Next, the authors argue that in RSU X the difference in terms of treatment between “rich” and “middle to poor” patients are real and apparent (p. 256), but, again, the authors only provided one answer from one patient. The same mistakes happen with patients with BPJS and patients without BPJS that the authors argue the difference of treatment they receive is apparent at RSU X (p. 257), but the evidence provided only comes from two patients.

The same mistakes happen again at the notion that most patients see doctors as the “who-know-all” person (p. 256) thus, the decisions doctors make are based on their knowledge but do not provide any patient or people that think likewise. The same statement also shows a fallacy in ethos because it is oversimplifying different perspectives. The purpose of this statement is to show society’s perspectives about doctors. However, the way this statement is provided is oversimplifying society’s perspectives. How society perceives doctors is illustrated as “not knowing enough” about the actual condition of doctors. The reason why this statement gives a “bad” image is that, again, the authors do not provide sufficient evidence or a detailed explanation. In short, the fallacy of logos and ethos in this statement is intertwined.

Another logos fallacy is the causal fallacy. The authors argue that the patient’s worry is one of the reasons that lead to the patient’s complaints about the service of the hospital (p. 257). However, no detailed explanations are provided on how the rate of worry gave rise to the number of complaints. Next is another generalization mistake. The authors suggest that one statement from one patient about how they are receiving special treatment because of kinship relations with one of the hospital staff gives an illustration about how doctors and the staff of the entire RSU X are using affection, not professionalism (p. 258).

Enough with logos, there are ethos and pathos mistakes on page 261. It happens on the same statement. The statement is that it is the doctor’s fault the patients are feeling abandoned by them because the doctors are not providing helpful information regarding the patient’s condition. However, from pathos stands, this statement is aligned with most people’s thinking (it’s the norm), but the authors do not explain why the doctors should be the ones who take the blame (why things should be like that). The authors only provided a statement from one patient then concluded that it is the doctor’s fault. The ethos in this statement is that the author’s grounds for this claim is only a patient that does not know enough the workload of a doctor thus oversimplifying the doctor’s sides of the issue that the reason they “abandoned” them is to observe the patient’s condition.

Next is another pathos fallacy. The authors argue that the patients should know better surrounding their health because information technology is everywhere now (p. 262). However, not all patients have access to such technology and not all patients have the capacity to operate it or understand the content they are looking for (maybe because of their education and such). Because it is the norm to look up one’s health condition on the internet does not constitute that it is how things should be.

Lastly, I want to explain the ethos fallacy but in general, (I am not referring to any particular statement or pages). In most of the analysis sections of this article, the number of doctors interviewed is not sufficient to argue about the hospital or the doctor’s side of the issue. The authors often explained how the reason things happen — say providing unequal treatment for patients — is because the hospital is busy (for example, look at p. 257). However, no doctors or hospital staff say such things. Thus, readers could interpret that the authors are appealing to the wrong person. This happens often in this article. Also, this particular example could provide yet another example of logos fallacy because there is no actual data to support such a claim.

The conclusion of this article provided a quick and short overview of the entire article. The authors re-stated the argument and provided a quick overview of the analysis of the issue such as the economic differences between patients with BPJS and patients without BPJS as one of the examples and reasons for the imbalance of doctors-patients relations. The authors end the article by stating that even though most doctors-patient relations are imbalanced thus creating disparities in treatment, services, not all doctors are like that, and some doctors are willing to back down from their high grounds.

There are critics I want to tell about this article. First, the authors present that the name of the informant will be written with their initials (p. 254), but most of the informants are written with their names (or maybe a disguised name but the authors do not explain it). Next, there are some informal Indonesian words in this article, such as diagnosa and dikarenakan. Then, the authors stated that they are documenting the phenomenon by taking pictures to give a more realistic impression of the issue (p. 253), but there are no pictures in this article. Transitions between one sentence to another in some parts of this article are somewhat awkward. For instance, Meskipun memang tidak semua dokter bersikap seperti itu. Sikap seperti ini jelas menyalahi etika profesionalisme dokter… (p. 256). From “sikap seperti…” and so on are actually one part of the previous sentence. Hence, the sentence should be Meskipun memang tidak semua dokter bersikap seperti itu, sikap seperti ini jelas menyalahi etika profesionalisme dokter… There are many technical language issues in this article, such as the word dimana where it should be di mana. Also, the wrong use of punctuation, such as Hal yang dilakukan oleh pasien ini sangat fatal(,) Jika dicermati pada dasarnya… (p. 262) where it should use a dot (.) There is also an issue of inefficient sentences, such as Dari ilustrasi kasus yang terjadi pada seorang pasien maka dapat disimpulkan bahwa (p. 263) where the word maka should be removed to ensure there are subjects in this sentence.

Then, the authors kept saying about doctors’ ethics (p. 254–256) but did not provide about what is the doctors’ ethics. Doctors are special occupations with their own code of ethics, thus, it is vital to provide it for the readers. In addition, in the bibliography section, the authors insert Sabriyanti’s work but there is no Sabriyanti’s name in the body of the article that indicates the authors cited Sabriyanti’s work. The same problems occur with William’s work.

The authors used Parsons’ theory but no citations found in the body note or the bibliography indicate the work of Parsons. On page 266, the authors cited Fox while talking about Parsons’ theory but no indication indicates that Parson’s theory in this article came from Fox’s work.

Lastly, some repetition of information makes the article a little bit redundant. For example, the authors stated “. . . tetapi dokter pun ketika menjalin kontak secara langsung (bertatap muka) dengan pasien sedapat mungkin menghadirkan suasana yang bersahabat” (p. 263). Similar notion exist at page 265 “tetapi dokter pun ketika menjalin kontak secara langsung (bertatap muka) dengan pasien sedapat mungkin menghadirkan suasana yang bersahabat.” While there are times when an author needs to re-state information they already stated, in this article, I think there is no need to repeat this information. Even if the authors think that they need to repeat this information, I think it’s better to use terms such as “as mentioned before” or “like I was saying” or others saying that have the same tone. For substantial critics, I think the fallacies provided before could serve as critics for the substantial part.

To close this review, this article, for me, provided a bunch of insight. It widens my view that the relations between doctors and me are complex. It gave me knowledge about discrimination that is happening inside a hospital (I rarely need to go to the hospital). Even though the story of discrimination inside hospitals is everywhere, the actual example provided by this article makes it more real. It also gave me knowledge that doctors — who are often viewed as arrogant — do not come so because they want to, but because of the social dynamics that are happening in the relations between doctors and patients. Does the condition of doctor-patient relations need to change? Taking into account the importance of human health, I think it does need a change.