Responsibility at the Bedside

Updated: Apr 15

Author: Anish Natarajan

Author Affiliation: University of Central Florida College of Medicine

VJM Spring Edition 2026

Abstract

During a clinical observership at Nizam’s Institute of Medical Sciences in India, I encountered a moment on rounds that reshaped how I think about the relationship between efficiency and attention in patient care. A man recovering from an anterior cerebral artery stroke, without family nearby, had gone much of the day without being spoken to. The attending surgeon’s public insistence that the team “do better” exposed the fragility of attention within even high-functioning clinical environments.

Much of my medical training in the United States has emphasized the delays that shape care—prior authorizations, prolonged approvals, and logistical barriers. What distinguished this setting was not the absence of complexity, but the relative absence of delay. Care moved forward decisively, and the volume of pathology reinforced that the diseases we study are not abstractions. Yet the encounter suggested that speed and clinical volume alone cannot ensure attentive care, and that responsibility for the individual patient cannot be deferred to systems or workflow.

Article

It was nearly two in the afternoon when the surgical team entered the ward at Nizam’s Institute of Medical Sciences in Hyderabad, the usual rhythm of rounds momentarily disrupted by a sudden silence. A man lay in bed recovering from a recent anterior cerebral artery stroke, his weakness evident in the way one leg rested motionless beneath the hospital sheet. The attending surgeon stopped at the foot of the bed and looked around the room, his voice rising as he asked the team a simple question: had anyone spoken with this patient today? No one answered immediately. The only sound was the soft hum of the ceiling fan. He asked again, more sharply this time, whether anyone knew the patient’s name, where he was from, or who had been checking on him.

The surgeon then turned toward the patient and introduced him to the group himself. The man, he explained, worked as a food vendor in a well-known local market. He had moved to India from Nepal years earlier and had no family nearby. There was no relative waiting outside the ward, no advocate translating medical language into reassurance, no one to fill the long stretches between nursing checks. The surgeon’s frustration shifted from anger to insistence as he reminded the team that clinical care did not end with orders or procedures. “He has no one else here,” he said, before ending rounds with a directive that felt less like criticism and more like a moral correction: we needed to do better. In the moment, the exchange felt uncomfortably exposed, the kind of public correction that makes everyone in the room acutely aware of their own silence. I stood a few steps behind the team, looking down at my notes, unsure of what to do next. Only later did I come to recognize it not as reprimand for its own sake, but as a necessary reminder of what vigilance requires if patient care is to remain personal rather than procedural.

Watching the exchange, I kept thinking about how quickly everything else in the hospital seemed to move. The speed was undeniable, but so was the silence around this bed. The encounter reframed how I understood the relationship between system pressures and individual responsibility, a theme that continued to shape what I observed throughout my time there.

Much of my training has emphasized the delays that shape American care—prior authorizations, prolonged approvals, logistical barriers. What distinguished this setting was not the absence of complexity, but the relative absence of delay; care moved forward decisively, shaped less by layers of authorization and more by clinical judgment and necessity.

In the operating rooms and clinics I started to appreciate how volume itself becomes a teacher. With a population more than four times that of the United States, pathologies I had previously encountered only in textbooks began appearing before me with surprising frequency.

We saw meningiomas in various stages of progression, cases of Moyamoya disease treated with bypass surgery, and rare pediatric entities such as diffuse leptomeningeal glioneuronal tumors. Seeing them in person made it difficult to keep the comfortable distance that textbooks allow, and it changed the way I viewed what I thought I was preparing for.

I have long been fascinated by the idea that one organ facilitates everything about our thoughts, dreams, desires, ability to breathe, and functionally everything related to our consciousness and perception of reality. In neurosurgery especially, the brain is simultaneously held as this object of reverence but treated with an engineer’s precision. Each of the tools we saw being used in the operating room (OR), from the diamond burr drill to the cavitron ultrasonic surgical aspirator, was developed for a shared purpose: targeted intervention while minimizing harm to the surrounding tissue. Watching these instruments at work reinforced the idea that neurosurgical care is defined not only by what is removed or clipped, but what is left intact. The same precision used in the OR, however, does not protect against oversight.

What I continue to sit with is not simply the speed of care I observed in Hyderabad, but how easily attention slips, no matter the environment. A ward capable of mobilizing an operating room within hours could also allow a man without family to pass half a day without conversation. The surgeon’s reprimand lingered with me because it complicated what I thought I had understood. Efficiency did not automatically translate to presence. Volume did not guarantee vigilance. The absence of bureaucratic delay did not prevent moments of inattention. In that sense, the rounding encounter felt less like a commentary on Indian medicine and more like a mirror held up to any healthcare system, including my own.

While the practice environments and administrative structures between Indian and American healthcare differ profoundly, the diseases themselves do not obey borders. Occluded vessels predictably result in anastomoses; subarachnoid hemorrhages present with similar constellations of symptoms; and neural tissue responds to injury with a universal pattern of degeneration and repair. Biology remains constant. Care does not.

If systems differ in their speed, their resources, or their constraints, they share a more uncomfortable truth: no structure is immune to blind spots. Policy cannot carry that responsibility for us, and workload cannot excuse it either. It rests, quietly and repeatedly, at the bedside—especially for those who have no one else standing there.