Doctors aren't saints

A man goes to the doctor with an ailment. The doctor cures this ailment and asks to be paid. The man refuses to pay, and says that doctors, by virtue of becoming a doctor, have special moral obligations to patients and society and asking for payment for his services brings into question his humanity, his morals and the oath to honor the profession. He goes on to caution that such demands would ruin the faith of the public in the profession and portray doctors as being inconsiderate and materialistic.

It is unfortunate that the current strike by doctors is viewed in such a perspective, that a strike is incompatible with the medical profession. It is disappointing that the Human Rights Commission denounced the strike by suggesting that doctors were trying to hold ransom the rights of patients for material gain when it wasn’t so. The strike was limited in that doctors attended emergencies and care was provided for inpatients. As advocates of human rights the commission should rather question why policy makers allow unnecessary suffering of patients by improper allocation of healthcare resources.

While it is true that doctors have special obligations to his patients and society, a person who choses to become a doctor does not make any declaration, implicit or explicit, that he/she will abstain from trying to make his/her life as fulfilling as possible and like any other individual they too have the right to pursue happiness. The actions of doctors should be judged by the same standards as those used for other professionals. When the Civil Service Commission fails to provide a just payment for their services, it is unfair to suggest that doctors should work under any circumstance. Several doctors, while employed full time as professionals, have been denied the professional allowance and exploited due to the commissions’ refusal to review its rules.

If doctors have special obligations, they can demand special benefits and go on strike, as long as the demands are reasonable and it does not undermine patient care. The provision of healthcare is a joint responsibility of the government, hospitals and doctors and each element should support the other.

THE PUBLICS' MISTRUST IN HEALTHCARE

Trust is a fundamental element in interpersonal relationships and the importance of trust within healthcare cannot be stressed upon enough. Patients present themselves to healthcare providers at their most vulnerable and must be able to trust both the institution and the individuals involved in their care. They must be able to trust that these individuals and organizations are competent and have their best interests at heart. At present this is far from true in this country. Most patients do not trust the institutions nor the individuals providing the care. They are weary and suspicious of any medical encounter. Numerous accounts of mismanagement, maltreatment and neglect by doctors are exchanged daily in the queues at IGMH or ADK. People would rather go abroad for the simplest ailment than get a consultation here at home. 

Several factors have contributed to the buildup of this mistrust. 

Firstly, as the face of healthcare, some doctors do not bother or are not trained in creating a healthy doctor-patient relationship that is crucial to the success of any treatment. Most Maldivian doctors are trained in South Asia, either in India, Nepal, Pakistan or Bangladesh, where a paternalistic approach to patient care is acceptable, practiced and used in training. The doctors know what is best and the patient should do whatever the doctors order, no questions asked. Procedures can be done on patients even without consent. There is no room for the patient to refuse treatment. On daily rounds it is common to see doctors scolding patients for not complying with treatment. The rights of the patient and proper ethical conduct are hardly an issue. Thus it is not surprising that such incidents are all too common in our hospitals where the doctors are either trained in or are from such countries. The possibility of trust in such an environment is impossible, especially when Maldivian patients in general ask more questions and are somewhat more aware of their rights (hence the popular belief among doctors that maldivian patients are ‘troublesome’ and ‘difficult’). 

Secondly, healthcare institutions and individuals do not protect the patients’ rights of confidentiality and treat their medical information as coffee-time gossip. It is all too common to hear doctors discussing personal details of their patients for their amusement, or lab technicians  discussing a patients’ paternity test. Healthcare professionals owe a duty not to disclose information against the patient’s wishes as medical confidentiality is an important feature of the doctor-patient relationship. 

Thirdly, healthcare institutions are all too keen to cover up medical mistakes and no framework exists to deal with such mistakes. Hardly any incident is thoroughly investigated and proper actions taken, and those wronged are not compensated. There are no professionals trained in legal medicine and those sitting on the ethics committee lack any training in the area.

Fourthly, there is no institution to regulate and standardize healthcare. The recruitment of expatriate doctors, who make up majority of doctors especially in the atolls, should be more stringent and registration at the Maldivian Medical Council should be followed by a licensing exam. Many are familiar with the account of a cook who used to work in one of the islands as a doctor for several years. There is a lack of standardized management protocols for common conditions, and adherence to those existing protocols is limited and not enforceable. There is no code of ethics or a code of professional conduct for doctors, which is a necessary tool for the regulation of the profession. Policy makers should consult healthcare professionals in making decisions that affect the health of the population in general. The recent changes to the appointment system at IGMH(which has fortunately been reversed), seriously violated a patients’ basic right to choose his/her healthcare provider, and only intensified the publics’ mistrust.  

In such a setting, where healthcare is not standardized or regulated, and where the healthcare providers are not bound by any obligations, legal, professional or otherwise, the publics’ mistrust towards healthcare is not surprising. It has resulted in the increased number of second opinions being sought and increased the requests for referral abroad. Failure to comply with treatment is commonplace. It has also increased the number of people turning towards other sources of treatment. 

Having said all this, I know of no doctor who wishes harm on his patient. Perhaps it is the combination of several factors rather than a single one that has led to this mistrust. Trust is a potentially powerful variable affecting healthcare decisions. And as such, both healthcare institutions and individuals should work to regain and reestablish this trust, by building a relationship in which the values and goals of both parties are clearer to each other, one of shared decision making, and one which promises to increase patient satisfaction and lead to greater understanding of treatment and illness. 

STATUS OF THALASSEMIA IN MALDIVES

Thalassemia, at present, is one of the most challenging hematological disorders . Patients with ß- thalassemia major need regular blood transfusions in order to live and the resulting iron overload requires chelation therapy.  The problems facing them and their parents are immense, challenging them physically, emotionally and socially. 

In the Maldives thalassemia affects about 0.16% of the population, and is found throughout the country, with the highest rate found in K atoll, most likely because an address in Male’ is given at the time of registration at the National Thalassemia Center (NTC).  Apart from K atoll, the highest rates are found in N, H.Dh and L atolls. 

To date a total of 670 cases has been registered at NTC. The number of new cases registered has not declined over the last five years, with about 28 new cases on average being registered over the last 7 years. Last year saw an increase to 39 in fact.

Considering that the country has two centers dedicated to thalassemia (Society for Health Education and NTC), and the government spends roughly $5000 per year per child for the treatment of a child with thalassemia above 12 years, this current trend raises the questions whether these centers are doing enough for the prevention of thalassemia. 

The current preventive program focuses on discouraging the marriage of carriers to one another, thus increasing the number of carriers throughout the country. And in Maldives where the social circles are small, the chance of intermarriage of careers is high. And their career status will not be a deterrence to getting married or having children. They will continue to take the risk and hope for that 75% chance of having a normal baby. 

The approach has not helped in reducing the number of new cases as most of the children with thalassemia are being born sadly, to those who know of their career status at the time of marriage, and to those who already have a child with thalassemia. This is an important observation that needs to be addressed in the prevention program as just the mere knowledge of the risk has not prevented couples from having children. 

The goal of the program should be to lessen the burden of thalassemia in at-risk families, accomplished not only by providing information about the risk but also providing options for dealing with it by helping at-risk couples obtain prenatal diagnosis and selective abortion, or by helping them to cope with the birth of an affected child. 

The current management protocol too needs revision to include oral iron chelators in the treatment. At present only a select few are being provided oral iron chelators at NTC as the treatment requires regular monitoring for side effects. Recommendations have already been made to the Min of Health and Family, in view of the considerable improvement in the serum ferritin levels in patients on combination therapy, to start the treatment at the regional levels, but its implementation has yet to materialize. 

The adherence to the current management need to be enforced more rigidly as reports of mismanagement are quite common at the regional and island level. Most doctors employed at the island level are not well versed with the disease and have different opinions regarding when to transfuse, how much to transfuse and on chelation therapy. 

And sadly the psychosocial impact of the disease is completely ignored in the management. Compliance levels are lowest at the adolescent age group and it is essential that they get the proper psychosocial support including a clear understanding of the disease. In a survey conducted amongst adolescents at NTC, 90% did not believe that they had complications despite not complying with treatment and having their serum ferritin levels well above the target range. The extent of complications have yet to be documented. 

A total of 140 of those registered have died so far, and from 1997 to 2007 each year about 8 children have died at the average age of 8 years. This young average age at death should be a matter of concern in a country where all aspects of treatment are free of cost and where treatment is readily available. No other single disease enjoys this level of commitment from the government and the statistics should be in favor of this support. 

As it is the status of thalassemia in Maldives is not encouraging and revisions need to be made in both the preventive and treatment aspects. Genetic screening should be accompanied by improved counseling. Effort should be directed towards prenatal diagnosis programs. Combination therapy for iron chelation need to be started across the country at regional levels and psychosocial support for both the affected child and family should be given. A comprehensive program encompassing public education, screening for carriers, genetic

counseling and prenatal diagnosis has markedly reduced the incidence of ,B-thalassemia major in

several countries such as Cyprus and replication of such a program in the Maldives is necessary to lessen the burden of this preventable disease.