A fair deal!

By Dr. Muhammad Hafizullah

 “We understand doctors do not have the time to hold patients’ hands and shed tears on their bedside, but they should be more compassionate!” said Anika Khan, a non medical member of the faculty of CBEC, Sind Institute of Urology and Transplant (SIUT) while facilitating second workshop on Bioethics held in Peshawar under the umbrella of Khyber Medical University.

This was the final concluding session of two days workshop organised at the auditorium of Lady Reading Hospital.

She was giving the public version of what people want of doctors. Most of the participants were trainee medical officers and junior members of the faculty off Postgraduate Medical Institute, Khyber Teaching Hospital, Hayatabad Medical Complex and Khyber College of Dentistry.

She narrated an incidence relating to a doctor, “The gentleman at reception very curtly replied that in the hospital we only have patients -without any prefixes and postfixes.”

The doctor concerned wanted to be registered as a patient with his full identity being recorded. She alleged that hospitals and clinics purloin a person of all lifelong achievements.

She lamented that hospitals should do more to preserve the honour and dignity of their patients. She highlighted another dark aspect of our hospitals where as doctors and paramedic staff refer to patients as ‘bed number’ and ‘case’ as against their name.

She implored the loss of identity, a patient suffers, as one is admitted to a hospital. This must be a blind spot of our medical training as a whole as she was describing her experiences and observations made in Karachi which are applicable to all the other parts of our country.

In our quest of treating all patients equal on the merit of their illness disregarding their social status, we probably have gone too far! As a senior doctor first lesson that we have to inculcate in our juniors - the trainee doctors, is to treat all patients equal.

We urge them very strongly not to be influenced by social factors. In developing countries we have to dig in deeper into socioeconomic history. The health care system, even in government tertiary care hospital, still expects a lot of inputs from the patient and their relatives.

We do not have the luxury to decide about a course of treatment, write the drugs in the chart and expect that those drugs would be made available to the patient. We have to first think of securing the procurement of drugs or disposables while considering the options of treatment. Abroad the responsibility of the doctor is to write the preferable treatment in the chart and the system ensures that those drugs are supplied to the patient - free of cost in NHS hospitals in UK.

Some safety nets exist in most systems in the world by and large, where as insurance coverage offers similar services in other parts. Here in Pakistan, we have developed similar provisions in some of our departments but based on individual efforts and departments. The need is to institutionalise the system at provincial or national level.

Most doctors, nurses and paramedical staffs do not make conscientious efforts to learn patient’s names and then address them appropriately.

Abroad special efforts are made to learn names and many jot hem down on a small piece of paper and address the patients by their names. In outpatient departments patients are ushered in by their respective names and not by numbers. In hospital rounds, again, patients are addressed by their surnames and similar practices are followed by nurses, paramedics and porters. Special efforts are put in to preserve the identity and enhance prestige of the patient.

“My doctor after doing the necessary tests, put two drug coated stents in my left artery and another non drug coated stent on right side as the vessel was big and the blockage was short.

I have been prescribed drugs which I have to take for the rest of my life. My doctor discussed with me the pros and cons of Bypass surgery and after discussions I opted for angioplasty,” explained Rashid who had the procedure performed in Birmingham, UK.

Such detailed discussions do not take place over here for a variety of reasons. An important factor that is highlighted time and again is that our doctors do not explain pertinent details to the patients. Most are rather shy to go into details and explain benefit and detriments of a procedure.

Though at many occasions patients and their relatives refuse to get into the nitty-gritty by saying, “you are the doctor and you know the best: you decide for us!”

Some do not want to know about the failure rates or possible side effects. In my opinion, it is our sacred duty that we must explain the procedure to be performed in simplest words with easy to understand examples without hiding behind medical jargon and technical ambiguities.

“A nurse came in the middle of night asking my patient to affix his thumb impression on a piece of paper without explaining anything- and this was supposed to be consent for a highly complicated operation,” continued Anika Khan, while describing the woes of her patient in a tertiary care hospital in Karachi. Same is the routine being followed in most other hospitals.

We -as doctors- do not spend adequate time and efforts in obtaining a proper informed consent. This subject is never addressed at graduate level and is barely mentioned in postgraduate training. Special courses should be organised for communication skills and on obtaining informed consent.

Usually the senior most member of the team should take the responsibility of obtaining the consent. The surgeon or physician concerned should sit with the patient and relatives and explain to them the procedure, the indications, the likely outcome, success rate and possible complications. All the pertinent questions must be answered patiently.

The patient should be asked to sign the papers, only after completing the whole exercise. Here, very unfortunately, this onerous and very responsible, job is at times left to juniors who, sometimes, pass on the buck to paramedical staff.

Many patients being illiterate, cannot read the otherwise perfunctory details and trusting the profession affix their thumb impression unhesitatingly.

Special efforts have to be put in to preserve the dignity and honour of every patient. Time spent on writing names on patients’ bedside should be encouraged.

A prefix must be added while addressing the patients as per our traditions and customs. There is absolutely no doubt that we have to train not only doctors but all nursing and paramedical staff to talk to their patients.

Permission has to be sought before even touching a patient for examination. Even an oft repeated procedure like taking a blood sample should follow proper explanation and permission of the patient.

The attitude of staff has to be sympathetic, always considering one’s own self in their shoes. We should implement the teachings of our religion in our routine for the benefit of our patients.