The Dead is Not dead

I have dedicated my career, running into decades, to understanding health, diseases and the cause of death in various circumstances, including medicolegal (forensic) cases, and I'm still amazed at how much there is to know about these subjects. Sometimes, it is difficult to make sense of the dynamics of health and diseases. However, in my experience across different regions of the world through the opportunity of working with the living, the dead and their families and communities, I have come to realise that Life is a continuum in repeating phases of health, diseases and death.

The book, The Dead is Not dead, is an original work which sets out to discuss an uncomfortable subject, a topic that is not often considered an icebreaker in any meeting or social gathering. It is a discourse about the Dead and issues around handling their bodies in a dignified manner and respectful interaction with their families. There is the awkwardness usually elicited whenever “death” or “the Dead” becomes a subject for discussion. It is so much that people even find it difficult to conceive the reality of their mortality and that it is only a matter of when – and not if – death will occur. 

Only very few people in the world wouldn't have experienced the demise of a family member, friend, loved one, or neighbour. Everyone has had such an experience. We are inundated daily with media reports of deaths in different contexts and circumstances. In a way, we have witnessed death and the Dead. One of the challenges is being able to talk about the deceased in a manner that is not laden with technicalities and sentiments. Therefore, this book presents the topic in a straightforward narrative, as much as feasible, which will be understandable to the lay public. At the same time, it provides some valuable insights for professionals in forensic medicine and science and the related fields, concerned institutions and authorities on some of the complexities of moving parts inherent in the management of the Dead, especially about the needs of their families, friends and communities.  

In addition, the relevant authorities, institutions and practitioners could reflect some more upon the relevance and implication of their actions, inactions and responsibilities in managing the Dead, especially in tragic circumstances/emergencies, and how their actions may impact the families of the deceased, their communities and the general public. It is never over following death because "The Dead is Not dead!". 

Meanwhile, you can click the highlighted text and order the book online. Your copies will be dispatched to any part of the world through UPS courier. The Dead is Not dead is our shared responsibility to the biphasic nature of holistic care and dignity and is a tribute to everyone who has experienced the death of a loved one and to practitioners, institutions and authorities who handle issues related to the dead, their families and communities.

The Dangers to Forensic Investigation driven by social media furore: MohBad Example

The internet has revolutionised the availability of information in an interconnected world, and social media has supercharged information sharing. Often, there are no filters and with a device and internet access, everyone is potentially an expert in any subject matter on Earth! However, this phenomenon comes with heavy risks: fake news, misinformation, and abuse of information. There have been tragic consequences of the situation, including suicides. homicides and accidents.

Frequently, an incident goes viral on social media and may require the intervention of concerned authorities by instituting relevant investigations on such matters.  The dangers lie in the effect of social media on the perception of people and how this could substantially influence critical decisions that border on freedom, well-being, and the lives of others. The reality is that, apparently, everyone consumes social media "products.” to some degree, even at the highest level of governance and decision-making organs. There are hardly any private or public organisations or entities of repute that do not have some form of social media handle for engaging with their audience and the public at large. It is important to assess the impact of the social media “wave” in the sail of the policy and practice ship in all areas of human endeavour where the tide could, mistakenly, be measured by the perception of the sea level and not necessarily by the facts thereof.

The recent death of a young and upcoming musician, popularly called by the stage name, MohBad, is a test case of how many commentators on social media (some of whom wield considerable influence) have run ahead of investigations to make categorical calls on what caused the death of the young man without recourse to the facts of the matter or available evidence. The real danger is how this is shaping the attitude or disposition of those (including the police) charged with the responsibility of investigating the death. The death of anyone is tragic but what would be a double calamity is the miscarriage of justice driven by emotions and the propensity for quick retribution by a vocal crowd. Sadly, it does not serve the interests of the dead, their families or the public to pursue acrimonious paths to “closure”, because it simply leads to a blind alley where everyone lives in the dark, injustice thrives, and resentment soars.

There is a need for training and retraining of investigators in this era of ubiquitous exposure to media of different characters and intents, where misinformation has become an occupation for some, who live off passing their imaginations as facts and deliberating sowing confusion as their power of leverage. We need to have police officers and other investigators who are availed modern training that conditions them to resist the strong urge to work from a predetermined answer to the question. Rather, to build a team of investigators and experts who formulate the right questions and hypotheses in their approach to investigation and tune off the distracting cacophony of social media narratives, that are sometimes driven by personal interests and pecuniary compensation. The obsessions over “hits”, “channel subscriptions”, and “followership” are in overdrive, and insulating investigators and others that play significant roles in the justice mechanism will be crucial to preserving our civilisation and preventing a descent into anarchy.

Meanwhile, death is inevitable. It could occur at any time and in any age group. However, when any death appears unnatural, it is mandatory for relevant authorities saddled with the responsibility to conduct a proper forensic death investigation. It is very crucial to follow the facts and route the evidence leads. Any actions pandering to the social media frenzy have an unacceptable risk of ending in a cul-de-sac with many casualties on the trail, including the reputation of the investigating agencies. 

MohBad life matters. Other lives also matter. The social media “commentators”, “investigators, “panels” and “judges” are not particularly known for their objectivity predicated on facts. Caution is advised.

Reported Death of 3 Medical Doctors in a Hospital in Lagos State within 5 Days! A Call for Investigation

The death of three medical doctors of the same cadre and in the same hospital of the same State within an interval of 5 days stretches the phenomenon of happenstance. This is a relatively massive loss in a context with a staggering patient-to-doctor ratio. It is also frightening for colleagues who work in the same environment. The devastating impact on the families and loved ones of the deceased colleagues can only be imagined.

Doctors in Nigeria have complained of the heavy burden of rendering care to patients in an environment with an acute shortage of healthcare workers, crushing insecurity (with some medical doctors still in the captivity of kidnappers across different parts of the country), crushing economic impact with high inflation and stagnant remunerations, and a toxic work environment with unhealthy inter- and intra-professional rivalries and relationships that make going to work a daily survival, coupled with a lack of amenities and an unsafe workplace. Recently, many doctors have quit their services and are relocating to other parts of the world, mainly to escape the unrelenting insecurity, comparatively poor remuneration, and lack of job satisfaction. The death of three senior doctors in one hospital within five days has only worsened the statistics in that setting and, understandably, created fear in the minds of colleagues and the entire community.

The relevant authorities in Lagos State should give these tragic incidents the seriousness they deserve. There are already some agitations among the colleagues of these doctors about the apparent lack of urgency in addressing the dire situation and grave concerns about health and safety at the workplace. The matter should not be dismissed as a coincidence. The management of the hospital is expected to have commenced some investigation to understand what common thread might have run through these deaths in such a remarkably short period of time. The medical association must not relent in ensuring that the facts of these incidents are evident, in preventing similar deaths, or in better managing either communicable or non-communicable diseases that may be in the background of these deaths. Furthermore, the bereaved families deserve answers they may require about the cause and circumstances of death.

"Media Trial" of Healthcare Workers: How Should an Affected Physician Respond?_Part-2

It is important to look beyond the "trial" headlines and take a wider view of this phenomenon. In any trial, there must be at least a complainant, whether an individual, organisation or the state. The phenomenon of the "media trail" could be a pointer to a wider sense of patients' dissatisfaction with the care provided to them, coupled with a nebulous mechanism for seeking redress. The media becomes a ready vehicle for conveying their grievances or lack of satisfaction with the care provided to the patients.

Understand what "satisfaction" means to your patient. Healthcare workers, especially physicians, often believe erroneously that "satisfaction" means successful medical treatment. While a good clinical outcome is usually the goal of medical intervention, using it as the only measure of patient satisfaction is to be steeped in the "end justifies the means" mindset. However, patients are different, with disparate values and dispositions. Satisfaction with patients entails the process, the procedure, and the outcome. To attain such a state of fusion of expectations, physicians may need to go back in time to the timeless counsel of Hippocrates: "It is more important to know the person than the disease the person has." Simple gestures such as calling the patients by their names, turning up to clinic schedules on time, taking into account patients' circumstances and aligning care, as much as possible, to their peculiar conditions, exploring cost-effective options in the best interest of the patient, etc. In such patient-centred care, the media would scarcely have any foothold in the doctor-patient relationship.

Have a functional conflict resolution mechanism. Discord is inevitable in any human interaction or transaction of any sort. How we resolve the discordance matters a lot. It is particularly relevant in the context of healthcare delivery. How many hospitals or health facilities have "complaints and suggestion boxes" that are regularly reviewed by a dedicated staff as part of total quality management with a robust feedback loop that gives affected patients or their families the confidence that their concerns are addressed? How many health institutions include in their initial contact with patients some information about how complaints could be channelled, including details of the office of an ombudsman to contact? Often patients get lost in the maze of regular hospital operations, and when they have some misgivings about the care they are receiving or the conduct of their healthcare provider, they usually don't know who to turn to for redress. It is a loophole that may be exploited by extraneous interests.

Media outreach. The media (both organised and social media) is a veritable mode for health education, prevention, and promotion. It will serve the greater public good for medical practitioners to reach out to the organised media on relevant aspects of healthcare services and peculiar features, including ethical obligations, in the care of patients. It'll also be relevant for media houses to have in-house medical correspondents, who are qualified medical practitioners, on part-time or full-time engagement, to serve as a clearing house for health-related issues and provide informed reporting on such matters. Furthermore, medical practitioners and health facilities should maintain an active social media presence for health information and public enlightenment. Physicians should find their place and voice in that space so that third parties do not control the narrative on health-related matters. A proactive approach is required.

Healthcare and media practitioners can work as partners in the best interest of patients. Trials should be reserved for the courts and related statutory authorities.

"Media Trial" of Healthcare Workers: How Should an Affected Physician Respond?_Part-1

These days, it is not uncommon to have running "court" sessions hosted by various media, including newspapers/magazines, radio/television stations, and social media platforms, on patients' case management. It is usually against the backdrop of a lack of satisfaction by the concerned patients, guardians, or their families about the care provided to their loved ones or where there is an actual or perceived medical error, misadventure, negligence, or mismanagement.  The "media panel" usually combines multiple roles and coordinates all the operations and functions, such as "investigators", "witnesses", "jury", "judge" and sometimes "enforcement agents".  It is a disturbing trend in some contexts, and this has created a chain of vulnerability for everyone involved. The risks for the patients, their families, healthcare workers, their facilities, and the general public do not appear to have been deeply thought through by the proponents of this media furore. Sadly, it also has a veneer of “entertainment," as the private lives and sensitive medical dossiers of patients are exposed to a participating audience enticed to weigh in as "experts" on the subject matter.

If a physician or their facility is the subject of this "trial", what should they do?

Do not appear or participate in such media "court". There is no place for medical doctors to defend their care of patients in a media bazaar. There are regulatory bodies in all parts of the world that govern how medicine is practised. The respective Medical Councils have internal mechanisms for addressing any reports made against a physician in their medical practice or conduct. Going public through a media house to "defend" oneself against any complaints or accusations may cause irreparable damage to the doctor-patient relationship and the commitment to respect and protect the confidentiality of the patient's medical record. The ethical imperatives that guide the medical profession must be upheld at all times. A media exposé is not one of the recommended ways of preserving the sanctity of this obligation to standard practice.

Do not join issues with the media by presenting a counterpunch to their narratives in public. You'll never win that battle! It is not an engagement that is determined by who "wins" the argument or whose logical trail is the stronger. No. Rather, it is often hugely driven by perception, sentiments, and reactions to the apparent imbalance of power between the patient and the doctor. Fighting the media war on that turf only adds gasoline to the conflagration. It'll amount to deepening the hurt for everyone involved, albeit inadvertently. At this stage of an apparently fractured relationship that makes a patient or their family approach these "media courts" for intervention, the physician's audience should be the custodians of the medical standards against which a doctor's practice will be evaluated methodically. Reserve your energy for that audit process.

If you are employed by a health institution, report the situation to the management of the hospital and your Medical Association or Medical Defence Society. However, for private practitioners who own their clinics or hospitals, your Medical Association or Defence Society must be quickly informed of the matter involving either your alleged malpractice, misconduct or any disputes that may have been brought before a media discourse.  A medicolegal advice that takes into consideration the peculiar circumstances, laws, and regulations applied to medical practice in the jurisdiction will be invaluable.

Take proactive measures by ensuring that your practice meets the medical standard expected of your expertise and obligations for patient health and safety at all times. Anticipate that your actions and inactions will be scrutinised and keep in mind that perception can be a reality for a significant number of people. Hence, as a physician, your words, conduct, and appearance could convey meanings and applications beyond what is intended, and in contentious situations, they could put your career and liberty at grave risk.

The patient is not your enemy. Patients are simply different. Nonetheless, the situation presents an opportunity to carefully examine factors that would have contributed to a patient submitting to a public discourse of their private life. A dispassionate review, including introspection, may reveal insightful dynamics that a physician must recognise in healthcare delivery.

Communication is Key to Patient's Satisfaction and Less Litigation

Physicians who make adequate communication a centrepiece of their clinical care will be rewarded with patient satisfaction and a significantly reduced risk of litigation.  From my experience in medical practice, most patients trust their doctors and believe that they are working in their best interests. Most of the frustration for the patient comes when there is a gap in communication between the doctor and the patient. Admittedly, in some contexts, with a huge patient-physician ratio, it is practically impossible to provide what could be considered "adequate" time, which varies depending on the patient and the circumstances of the consultation. However, doctors could be more intentional about ensuring that every patient attended to feels that the physician is in the moment, focusing all attention on their health state, actively listening, and speaking as applicable.

In some contexts, some things may be taken for granted. However, I have encountered many patients who did not know the name of the doctor managing their health condition! Yes, they didn't know. Did not dare to ask. And worse still, the doctor never introduced herself to them. The "blank shot" becomes established right from the beginning of the "relationship" and results in many debilitating blind spots in the interactions between the patient and their doctor.  Intuitively, we pay attention to someone we know. Subsequently, communication becomes a monologue by a "stranger" who wields considerable power over their health and well-being. On a deeper level, patients resent this situation but are usually helpless to do anything about it in some peculiar setting. However, they may become more critical of the processes and outcomes of their treatment, and occasionally, the degeneration could roll off the cliff, causing irreparable damage to that relationship, which is crucial to the patient's trust, compliance with treatment, and acceptance of health outcomes.

Now, nothing is taken for granted! Let's start with communication basics: First, introduce yourself to the patient, and in multidisciplinary healthcare facilities, indicate your speciality and role in their care. Then get to know the patient, especially their name and any other ways they may wish to be referred to. Patients don't like to be called "Patient No. XYZ". Personalizing care starts with proper communication and calling them by their names, especially with the right pronunciation and appropriate salutation, which will ease both the doctor and the patient into the right atmosphere for a meaningful healthcare relationship that results in a satisfactory outcome both for the patient and the doctor. And "satisfaction" does not always mean a consequence of an expected or better outcome.

Thus, a physician must make communication, in the full sense of the word, a key aspect of case management. It is equally important to take into cognisance the sociocultural milieu of the patient and communicate appropriately. In the communication loop, efforts should be made to ensure that the patient is receiving what is intended. There are occasions when patients have undergone laboratory tests, had diagnoses made, and had procedures (including surgical intervention) administered without understanding what they were being treated for! Yes, it happens, and it is not the fault of the patient. It is the responsibility of the doctor to ensure that effective communication has taken place and to continue to validate the status at every contact with the patient or their guardian. Patients or their guardians know that physicians are not infallible. Even when medical mishaps or errors occur, they are more likely to explore amicable remedial measures (where possible) outside of litigation.

Effective Communication in Healthcare should be a core subject in the training of medical students and other healthcare workers and should form part of compulsory continuing professional education credits.

Can a Medical Doctor Decline to Attend to a Patient? Yes, but...

I have been asked this question several times by colleagues who truly do not wish to attend to some patients who present either in their private clinics or in public hospitals. One of the significant reasons is financial transactions. Some patients have a history of repeatedly not paying their medical bills, which has put some private clinics under a lot of financial strain because they are not reimbursed for the services they have provided in good faith. These patients usually do not have any convincing reasons for not paying their health bills repeatedly, and they appear to take advantage of their relationship with the doctor or their facility to rack up bills. It is a dilemma that some medical professionals, particularly those in private practice, have come across on occasion. The dynamics of the patient-doctor relationship limit the physician's options and the debt recovery modalities to apply, including civil suits, available generally to businesses.

An ongoing romantic relationship with a person the doctor is involved with could tinge on their case management as a patient because of undue sentiments and conflicts that could go against standard practice. Doctors should not engage in an intimate relationship with a patient that they are directly treating, as the power imbalance will potentially breach ethical imperatives in medicine. Simply put, it's unethical! An accusation of exploiting the vulnerability of a patient would be difficult to disprove in the circumstances. It is also not unreasonable to anticipate that a doctor's clinical judgment and conduct may be impaired by an affair with their patient. A sexual relationship with a patient that a doctor is actively treating goes against the professional code of conduct in all contexts.

In other situations where a significant conflict of interest exists, such as when clinical assessment and treatment decisions for a patient could be deemed to be influenced by the personal gain of the doctor or their business concerns, and not in the best interest of the patient, it is better to remove oneself from the cauldron. In a patient-physician relationship, perception is basically "everything". Whenever it "looks" bad, a physician is better off staying away. In this day and age of social media and "trials in the public domain"  by all and sundry, it might take an entire career to undo the harm that a false impression has caused to one's professional integrity and reputation. The damage is often permanent. Hence, operating out of an abundance of caution could best serve the interests of all parties involved. If in doubt, consult your institutional policies or professional codes of conduct, which are available to all medical doctors.

However, we can't simply refuse to attend to a patient, can we? No, of course not. A doctor is under obligation to attend to any patients in an emergency brought to their attention in their position of care, irrespective of the profile of the patients or their relationship with them. Every effort must be made to save lives and stabilise the patient. Subsequently, the patient should be appropriately handed over to another doctor of relevant expertise or referred to another health facility for continuation of care. In a situation where a physician is already treating the patient, it should be explained to the patient that continuing care will not be in their interest and that professional obligations in the circumstance require referral to another doctor or hospital, as applicable.

Yes, a medical doctor can decline to attend to a patient, but such a decision should be made with the health and safety of the patient as paramount and on the canvass of doctors acting in the best interest of their patients and the medical profession by ensuring they remove themselves from scenarios that could become unstable, explosive, and detrimental to the patient, the doctor, and the profession. And doctors should be more assertive and proactive in this consideration.