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.
4 comments:
One of the key factors to earn trust in any industry is quality in both people and resources. Since there is no quality in most cases in either, the common people cannot trust institutions.
Good article.
Doctor/Patient relationship has a very large gap and it will take lots of effort by both of them to overcome the issue.
Doctor/Health care trust also needs to build up. I have even seen doctors going abroad for treatment which can be done locally.
I totally agree that Patients should trust institutions and the individuals in the healthcare system. And that Healthcare professionals must be able to make their own decisions depending on their findings and, there should also be a good Medical Malpractice law to followup incase of failing to comply their responsibilities..
There is also the other side of the coin. Does all patients comply with the decisions doctors make? If not, what next? who will be responsible?
This is a very big social issue, i think docs can play a role in participating in awareness campaigns.
Anyway, thanks for the ADD logo. Check your mail.
A patient must be given enough information
that a reasonable person would want to
know or should know in order to make a decision, and it is a right of the patient to act or not act on it. Patient autonomy and informed consent are important aspects in modern healthcare.
Doctors definitely have a large role to play here to regain the trust.
Very good article. It addresses a very important issue and touches upon important factors.
But i think it has looked at somethings very superficially.
First thing is that the places most Maldivians go for healthcare abroad and impicitly trust also has doctors mostly trained in South Asia. That hasnt resulted in a trust issue. Its very unlikely the Maldivian counterparts have a vastly different 'paternalistic' approach.
I would also like to point out that though we do champion consent taking, we should be clear in our head that consent is very different from giving adequate information. Informing the patient well, allowing them to make an informed decision is what we should be talking about, because the 'consent' is just another method for the health system to save their ass. Its the by-product of a system of defensive medicine which unfortunately in our zeal to copy 'good' things we have imbibed in letter but not in spirit. It is purely for our benefit and not for the patient even though many of us have this notion that once someone takes consent it somehow becomes ok. Its only ok once someone explains in detail to the patient about the procedure and takes his/her view into consideration. Then if one is worried about being sued or if that is hopsital policy he can get the patient to 'give consent'. Let us not kid ourselves.
One case I would like to cite is that of a Maldivian operated on in a leading hospital in Singapore, where the patient woke up to his surprise with a colostomy. After sometime when he had come to terms with it n asked when it would be removed, to his horror he was told it was permanent! But consent and all that was in order. Here i would even venture out to say that 'consent' helped the hospital and harmed the patient, cos he cant even sue them. But does it make that right?
I am also not sure i can agree with the statement that Maldivians ask more questions. I do accept i have been practicing for only 9years, but atleast in those few years i have not found Maldivians to ask more questions in general. They are quite demanding though, and i do appreciate that quality can help the health sector in a big way if we can better educate them to better channel it. So in that line we have lots of work to do, b'cos right now the 'demands' are for things like certificate to go abroad for physiotherapy or for explanation of patient condition at 12 midnight from ward doctor because the son/daughter was too busy to visit during rounds/or regular official times. I know to make my point i am citing very unusual demands but they are not uncommon. Let me cut short here for now (i do have some more comments) by agreeing with the point Yafaau's Daddy made when he points out that even doctors go abroad for treatment available locally.
Hope we can generate discussion to solve this very cruicial issue of trust, which we can all agree the current levels have a lot to be desired.
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