Physicians' experiences and perceived challenges working in an emergency setting in Bharatpur, Nepal: a qualitative study

BACKGROUND: Emergency medical care, including prehospital treatment, forms an important component of any healthcare system. Like most low-middle-income countries, Nepal has an emergency medical system that can be described as underdeveloped. Emergency physicians navigating this system may experience challenges or barriers in their treatment of patients. This study aimed to investigate physicians' perspectives on emergency and prehospital patient management in a low-income country, Nepal, and to understand the challenges and barriers they perceive in emergency treatment including both the prehospital treatment and the immediate in-hospital treatment at the emergency department.

METHODS: Using a qualitative study, eight semi-structured interviews with physicians working in a Nepalese emergency department were performed. The interviews were conducted between September and November 2021 and were audio-recorded and transcribed verbatim. Data were subsequently analyzed using the systematic text condensation method.

RESULTS: Four main themes and associated sub-themes were identified: (1) patients' sociocultural, educational, and financial factors (such as financial issues and financial inequality) and regional differences; (2) emergency department's organization and resources concerning human and material resources, protocols, and guidelines; (3) problems with the emergency department (ED) service's qualities and availability caused by an insufficient integration of the ED and the EMS, prehospital resources, and financial interests in the EMS; and (4) surrounding healthcare system's impact on the ED where, especially, the levels of organized primary care, governmental responsibilities, and healthcare structure were addressed.

CONCLUSIONS: The physicians identified numerous regularly encountered challenges and barriers. These challenges stretched beyond the ED and into various aspects of society. The patients' financial problems were described as the greatest problem, restricting the treatment due to a given patient's inability or unwillingness to pay for the required procedures. The physicians were thus restricted in completing their duties to the desired levels. The low quality of prehospital care and a lack of education and awareness of common diseases and symptoms in a significant proportion of patients were identified by many participants as being significant issues. The aforementioned challenges or barriers directly resulted in patients arriving in critical conditions that could have been avoided if the disease were treated earlier.