"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.

The Future of Forensic Science Practice in Africa: Mentoring

I have travelled to many parts of Africa, mainly on trips related to forensic medicine and science programmes and I have witnessed the tremendous efforts of colleagues who are working really hard to render services to their communities, teach and train younger ones, and conduct research to advance the frontiers of the profession. And they do this with limited resources in operationally challenging contexts vis-à-vis the economic, sociocultural, and political milieu. I salute their courage in not giving up due to incessant pushbacks that come in diverse ways, especially when one is devoted to upholding the standards of practice with integrity.

However, I have equally observed a missing link in the generational chain for sustainable standard forensic practice: a lack of mentoring. There is no doubt that some forms of forensic training, of different depths and scopes, are going on in different institutions or locations across Africa. The lack of mentoring is stalling the quality of the outcome of the efforts invested in keeping the trajectory of the generational relay on an upward and forward swing. Occasionally, a whole forensic service collapses upon the retirement or death of the practitioner-proponent. There is no one to step into the shoes and carry on the touch, and in most cases, an ill-prepared profile assumes the responsibility in a terrain that requires acute vision and a methodical approach, which are more effectively transferred by mentoring.

Mentoring is not merely about observing a more experienced practitioner in a given field; it is rather an obligation of mutual commitment between a mentor and a mentee. Mentoring in the forensic sciences, as in other disciplines, is a structured system for making an indelible impact on preserving and improving professional ethos and standards from one generation to the next. It does not, and should not, happen by "accident". It is not "compelled". It is not regimented. Instead, it is intentional, and everyone voluntarily involved in the process is aware of the modalities, expectations, and evaluation towards a common goal. What is called "mentoring" in some contexts is often resented either by the "mentee", the "mentor," or both and the whole foundation crumbles on a faulty premise. Mentoring is generally an engaging and enriching process for the parties involved, and on this ground, the result of it prevails.

Meanwhile, mentoring does not require a specific budget or financial allocation. It runs on the fuel of our time and commitment. Interactions with my forensic science students are quite revealing. The issue is not only about the forensic knowledge and skills that students acquire but also (and often more importantly), the "forensic attitude": attention to detail, measured, reflective, process-oriented, and team approach. This posture is not taught in classrooms. It is usually a product of mentoring. We need to do more of it in Africa, as a matter of institutional and professional priority, in the standard practice of forensic medicine and related sciences.

The Curious Case of the Boy with "Missing Intestine": Are we Dealing with a Medical Communication Issue?

In recent times, the media in Nigeria has been inundated with the news of a boy whose intestine mysteriously disappeared at a hospital, with allegations of foul play. The recent visit of the Governor of Lagos State to check on the health of the boy has, once again, brought the story to the limelight.

The details of the case are not available to the public, and it would be speculative to talk about what happened. However, it is apparent that there is a communication problem.  How could the intestine be "missing"? This word may have been used at some point in communicating the health status of the patient, and it is now driving the sensations around this story to the detriment of the patient's confidentiality.

How we communicate medical conditions or findings is as important as the information itself, especially when we are dealing with the lay public. Patients and their families deserve information and explanation, communicated in the language and nuances they understand, and in an ambience that accommodates feedback and clarification. Medical practitioners must be intentional about ensuring that patients and their relations understand what diseases or injuries are present, the planned course of action concerning further investigation (where required), treatment options, expected outcomes (including the possibility of failure), general and specific risks, and complications. There cannot be truly informed consent if these elements and other relevant ones (depending on particular patients, their families, and their contexts) are not in the ingredients.

Effective communication, especially in medical practice, is not measured merely by the volume of information provided to patients or their next of kin. Rather, it is determined by the extent to which they fully understand what is being transmitted to them. The power imbalance between the healthcare provider and the patient often comes into play in their interactions. The medical doctor must recognise the dynamics and put the patient and their relations at ease by assuring and demonstrating the primacy of their preferences in any medical decisions. This disposition must be reinforced at every opportunity because health facilities exist basically to care for people, and these are patients and their communities.

I hope the Lagos State government will undertake a thorough investigation as indicated and get to the root of this odd case of the "missing intestine" in the circumstance. However, it may well be that miscommunication and misinformation may have misrepresented the misadventure of medical interventions in this patient.

Meanwhile, all hands must be on deck to save the life of this boy. The commitment of the Lagos government is commendable.

Complicity of Professionals-2

About 10 years ago, I wrote a short note on the "Complicity of Professionals-1". After over a decade, the status quo remains the same. No, the situation has worsened!

Professionals, especially in Africa, could do more to promote good governance and development in their different contexts across the region. They possess comparable knowledge and skills to other practitioners in any part of the world. So, the puzzling question is: Why is there such a slow pace (if any) in development in these parts of the world, where they have professionals in different fields of endeavour, who could trigger and sustain modern development through their innovation and leadership of the various sectors? Interestingly, in a significant number of countries, professionals head their respective ministries, departments, and agencies: lawyers are usually in charge of the Ministry of Justice and Office of Attorney General; finance and account experts oversee the Ministry of Finance and relevant departments; medical doctors superintend the Ministry of Health; and a similar pattern is seen in other ministries. So, why are we not making appreciable progress in Africa?

I have identified a lack of courage as a major reason. The lack of courage to stand firmly on professional protocols irrespective of the pressure to compromise standards. The lack of courage to speak the truth to power based on conviction; the lack of courage to risk the power and perks of office by upholding integrity and transparency; the lack of courage to resign when it is no longer tenable to keep a position without the opportunity to deliver on the values that enhance the quality of life of the people served; and the lack of courage to shun parochial interests.

Africa, and indeed the rest of the world, can make more progress if citizens, including professionals, summon more courage to confront corruption, first by living by example and subsequently propagating this lifestyle both upstream and downstream of their cycle of influence, interactions, and transactions.  We cannot afford to retell this story every decade. The knowledge, skills, and tools needed to advance humanity are more at our disposal in this era than in any other period in our history. What are we doing with this opportunity? 

The Calm Before the Storm. Then COVID-19 Pandemic. And post-COVID-19?

As of 2018, I was neck-deep in an international forensic mission crisscrossing different parts of the world in an assignment that held deep meaning to my heart in the dignified management of the dead, including forensic human identification. Generally, there was some stability in the air. Travelling was normal: arrive at the airports, do regular security screening and check-in, and take off! Then arrive and disembark. And repeat. Crowded terminals were a usual feature of ports of entry and were expected. Life as we knew it was pretty regular, with its thrills and downsides. The dynamics of operations added elements of surprise and unforeseen circumstances.

2019 came by as fast as it could, and towards the end of the year, news about some unusual illness initially limited to a certain part of the world filtered in. Regular folks paid little attention to such a "sectional" event, and it appeared to be of concern mainly to international bodies or agencies that track diseases and their evaluation. In any case, no one was really certain about the significance of such little incidents of "unusual" diseases. However, the talking points grew louder towards the end of 2019 and the first quarter of 2020, when the global alarm was sounded about a disease of significance tagged COVID-19. Eventually, in March 2020, the COVID-19 pandemic was declared. Then life took a different trajectory, and everything we called "normal" turned upside down.

I was drawn into the deep fight against COVID-19 with my appointment as Chair of the institutional task force against the pandemic. It was a "life and death" assignment. We were fighting a disease that had never existed in humans before. There was no established manual to handle the global outreach, and humanity as a whole was making up protocols as we faced the existential challenges of a ruthless malady. There was confusion about everything, even from high places of advancement. Facemasks work. Facemasks do not work. Drinking bleach is effective! Bleaching agents are harmful. There was a cacophony of voices, and the pandemic caused divisions along political and socioeconomic fault lines. People died in the murkiness of narratives and the lack of coherent leadership. People died from the fear induced by the disease. People died from mismanagement of even ordinary medical conditions because of the shadow of COVID-19. Millions died from the disease and related medical and psychosocial complications brought about by the pandemic. We may never know the exact death toll from COVID-19, but it was a disease of the century that changed everything we regarded as "normal". 

2020 to the early part of 2022 was a period of "to be or not to be". I devoted my entire life and career to fighting COVID-19 as the head of the task force at our institution and knew the risk it posed to my life. However, it was a fight that must be fought if we are to survive. We usually prevail when we pull together and confront our common adversary, of which COVID-19 is unmistakably one. Sadly, so many lives were often needlessly lost, families were torn apart, communities were shattered, and our way of life was disrupted for about two years. We woke up every day with the thought and disposition to survive each day. The long-term plan was simply to stay alive. We abandoned the things that brought us together so that we could live. And amid the whole conundrum, we learned to come together by staying away from one another. Online meetings and platforms sprang up, and remote work and relationships became mainstream.

Now, in 2023, my mind is gradually getting back to "factory reset". I still have a nagging question: Is COVID-19 over? There are still echoes of the pandemic and its metamorphoses breaking out from time to time, and we cannot afford to be completely at ease. However, we need to know what risks we have as we gradually return to any semblance of "normal". Should we prepare for further dislocation of our new "steady state"? I don't know, but one commitment I would like to make is to return to my engagement with you on this blog. And I'm optimistic it will be more regular than in past years!