The other day while rounding on a patient, I was told by my house staff that ‘’sir we are giving ceftriaxone (an antibiotic) to this patient who has an infected bed sore. The culture from his wound has grown Acinetobacter (a highly resistant bacteria) which is resistant to most antibiotics, including ceftriaxone, and sensitive only to colistin (an expensive antibiotic). Sir, we have been trying to get colistin for this patient for the last many days, but hospital has not provided it so far. So, sir, what should we do? The patient is deteriorating day by day.’’ I had no answer to their question. I told them to speak with hospital administration again and escalate it further. From a layman perspective, patient was getting medicine (ceftriaxone), but was it effective and the right choice? The answer is no. The house staff were strictly prohibited by administration from asking the patient’s family if they can arrange it themselves. The family seemed reasonable to me, and they could have arranged it if requested given its necessity for the patient and non-availability inside the hospital. But doctors were not allowed to make any such request fearing blame and victimization. The ultimate sufferer was the patient.

On the other end of spectrum, I have observed that any medication – no matter how expensive it is – will be made available on a phone call from a politician or a bureaucrat. So, the real issue is not of funds, although I understand public hospitals are markedly underfunded. The real issue is lack of consciousness, fairness and self-accountability. If funds for some expensive medicine can be arranged for a patient of a politician, a bureaucrat or someone of considerable position, then they can be arranged for a poor patient too. No doctor wants to prescribe medicines for patients from outside the hospital if they are available inside. But are all necessary medicines available? The answer is no. If not available, then can those necessary medicines be arranged for all patients? The answer is yes for privileged and no for poor – most of the times. But the poor will be kept ignorant, and the doctor will be blamed for prescribing those necessary – but unavailable- medicines.

How have we arrived at this stage in our healthcare system where policies are made by the ignorant and implemented by the arrogant? The developed world has advanced and moved towards an era of digitalization and artificial intelligence in healthcare. But we are stuck here, still debating about who has the right to make medical decisions for the patient – the doctor or a clerk sitting in administration? The system is rotten from top to bottom and needs a major overhaul. We need a public healthcare system where everyone is accountable for their actions, where the center of attention is the patient and his/her health, where funds are available for all the patients equally irrespective of their social status or connections, and where healthcare workers are treated with dignity and respect instead of ridicule aimed at appeasing masses and bosses. Our patients, both poor and affording – need better care at our public hospitals.

There is no doubt that even in developed parts of the world, for example in the USA and Europe, compensation in academic medicine is less as compared to private practice. However, that comparatively low compensation is still enough for someone to raise a family of four, live a decent quality life and end up with handsome savings. Of course there is no upper limit of money one can earn, but, one does not have to do any other job apart from teaching medicine to give a reasonable and respectable life to one’s children. The situation is opposite, here in Pakistan. I am fortunate that I trained in USA, worked there for few years before returning to homeland and joining academic medicine here. I have some financial cushion, but most of my colleagues at my stage of career don’t.

Most of my colleagues wake up early morning, around 6 a.m., get ready for the hospital to teach and serve till 2 p.m., go to another hospital to see their private patients in the afternoon, go to another hospital in the evening to attend to few more private patients, and return home after 10 p.m. By the time they reach home, their kids are already asleep. Sunday is the day when they get to spend some time with their families. However, some would travel out of city to nearby smaller towns to see patients on Sunday. There is no easy path for them. If they don’t work like this, they cannot feed their families and maintain a reasonable social status expected of a doctor.

Monetary compensation aside, academic faculty is often blamed for incompetencies and misadventures of health policy makers. Academic departments are understaffed, overburdened, and lacking necessary infrastructure for effective functioning. Yet, they are expected to give results just like USA and Europe. Bureaucratic micromanagement and political interference have paralyzed institutions and demoralized hard working doctors. Status quo have engulfed most places, and authority has been placed with favorites who are not only incompetent but also self-serving.

So currently, given above circumstances and ground realities, what is the source of motivation for someone working in academic medicine? Just yesterday, I was teaching 3^rd year medical students in the ward. They had prepared a case history. We went over the case, analyzed all the details of history, examination and laboratory investigations. They made a preliminary diagnosis and were so excited to know that the diagnosis they made was correct after I showed them final CT scan report. Their faces were full of joy and accomplishment ---they had learnt something new—and I was both happy and humbled just like the parents whose child has taken a first step. I was full of joy too. This joy cannot be measured in terms of money or any form of compensation. Most of my colleagues are in academic medicine because they enjoy teaching medicine, it gives them a purpose in life and a meaning to their souls.

It was 2014. I was a first-year internal medicine resident in Maryland. One of the floor nurses paged me to come upstairs and attend to a patient who needed a new peripheral intravenous line. I had placed intravenous lines many times before, so I went upstairs quickly. As I was climbing up stairs to reach the 4^th floor where the patient’s room was, I was thinking in my mind that ‘’ this is going to be so easy today’’. Patient’s previous intravenous line had to be removed as it had stopped working. The nurse who paged me had tried a few times to get a new one, but she could not do it.

As I entered the room, I saw a middle aged African American male lying in his bed and the way he looked at me, I instantly realized that he was waiting for me. He was calm. I could see hope in his eyes. He had bad pneumonia and needed a new intravenous line to get his medications going. I introduced myself, explained what I am going to do, and after placing a pillow under his both hands, started looking for a good vein to work with. Both of his hands were swollen. I could hardly see any veins. Puncture marks from previous attempts to insert a new intravenous line were staring at me. I tied the tourniquet up around his right upper arm and asked him to make a tight fist which he did right away. I felt a vein and introduced the catheter inside after puncturing the skin. As the catheter was tearing his skin, I could see pain on his face, but he did not utter a single word.

There was no blood return in the intravenous catheter as I withdrew the stylet. The catheter was not in the vein. I removed it altogether and did a second attempt on the other hand. It failed too. The patient, though in pain, smiled at me and said:

''Dr Butt, whatever you do, do your best''.

These words have stuck with me since then. Whenever I see a patient, I remember these words. I have contemplated about the meaning of these words many times. What is the meaning of ‘’doing your best’’ or ‘’being best’’, especially in the field of medicine and healthcare where lives are at stake. Does it mean to win the award of the best doctor of the hospital or city? Does it mean being recognized by the administration or government? Does it mean stepping up in the hierarchy of leadership of medical institution and become a principal or a vice chancellor? Or does it simply mean that whatever position you are holding, how small or large it may seem, do your job to the best of your abilities, and keep improving as your only competitor is you.

Being the best or doing the best is not a destination, it is a journey, a continuous process, struggle, and calling. And the best thing is that anyone can do it in the hospital, starting from the floor cleaners till the head of the institution.

I finally reach the hospital, say hello to the security guard at the parking entrance, park my car usually in the second basement, and head straight towards the emergency room. Emergency room is right across the street from the main hospital building. There is an underpass which connects both. On the entrance of that underpass, there is an inscription written which reads:

I read it, internalize it and enter the emergency room not knowing what patients I am going to treat today, how many lives will be saved and how many will die as our treatments would fail them.

After greeting the residents and interns who have arrived already before me, I would ask, is anyone missing or late? And there will always be someone who is either missing or late. The senior resident would then start a brief investigation and try to locate the remaining team members. All will eventually come in. I am lucky that I get to work with some of the most amazing residents and interns in our hospital who are eager to not only learn, but also serve.

The day would start slow. It is early morning, people are still waking up in their homes, moms and dads are dropping kids off to schools, the working class is navigating the roads of the city and the laborers are lining up across main roads with their tools in the hope of finding some work. I could hear residents and interns chirping among themselves about what they are going to have in breakfast and lunch, who is going to work with who, and in what order they are going to take some time off. This is the best time of the day for them.

Soon, the patients would start to pour in. A young lady with fever and headache, a middle aged man with uncontrolled blood sugars and an ulcer under the foot, a young boy who passed out while going to school, a pregnant lady who is referred from obstetrical unit with low platelets—so on and so forth. The beds would fill up in a couple of hours and soon we will have two patients on each bed, and then three. Most of them would accommodate one another as they know that they would have to spend huge amounts of money if they go to a private hospital.

Right across the reception desk, there is a large standing billboard which reads: All the medicines in the emergency room have been provided free of charge on the directions of chief minister. And then there is a complaint number too written at the end of above message to lodge a complaint if anyone tells them to get medicines from outside.

We would start treating all the patients as they arrive. Antibiotics injections, pain killers, intravenous fluids, and drawing blood samples for laboratory tests—all sorts of interventions would start happening. I would see hope on faces of patients who will be improving. Despair and agony would be visible on faces of family members of patients who will be deteriorating. Sometimes a patient will improve within minutes and other times, a similar patient would deteriorate despite having the same treatment. There will be a lot of surprises despite all the medical knowledge and skills we have. Soon the emergency room pharmacy will run out of one or more of the medications and then we will be contemplating its alternatives. For patients getting admitted, we would be satisfying our inner selves by saying that ‘‘even if the patient did not get it here, he or she will get it in the ward’’.

There will be many who will go home better and happy. And there will be many who will be admitted for further treatment in the inpatient ward. And there will be some who would die in the emergency room despite all our efforts. The 12 hour shift would end. All the residents and interns will hand over patients to the next time and then go home.

I would leave too and on way back to the parking, entering that underpass that connects the main hospital building with the emergency room, I would read that inscription again: ‘‘ You are just a companion, and He (The God Almighty), is the true healer’’.