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The art that is medicine

DR BOIMA

HEALTH ISSUES

When a friend of mine took to his facebook page recently to air his annoyance over a Doctor who asked him where the mother of the child was when he had taken his child to the hospital, an avalanche of responses started pouring in; both good and bad.

 

Some came out with guns blazing settling scores from their previous bad encounters with doctors, some out of ignorance derailed off topic and howled insults around, and some mostly in the health profession tried to come to the rescue of one of their own by explaining what might have prompted such a question.

Unless we were present we would not know exactly  how the question was presented, after how long into the converstation, how the rapport of the doctor and the patient was to begin with, and what the motive of the question was apart from speculating. What is however evident is that a lot still do not understand the artistry that is medicine.

The interpersonal encounter between physician and patient remains a cornerstone in the art of medicine. Considerable research has explored various aspects of this relationship, including physician-patient communication, difficult patient interactions, and what physicians find meaningful in their work.

As part of this art we ask questions, lots of them! questions that may sometimes seem or appear unfair, daunting, uncomfortable or even annoying to our patients but we are just really trying to understand and have an idea of what kind of a patient we are dealing with; nothing personal! So unless and until we ask, we wont know and we wont be able to give the right treatment.

That is just how medicine works, we rely largely on the history and the cooperation (or lack therof) from the patients or guardians to give us reliable answers in order to make diagnoses. A good doctor is the one who is holistic in their approach and touch each part of the patient’s history and not just focus on the illness presented infront of them. According to the late old English Physician, Caleb Hillier Parry "It is more important to know what sort of patient has the disease than what kind of disease the patient has".

In his 2014 publication, Thomas R. Egnew, reviewed the literature and delineated seven behaviors expected during a doctor-patient interaction  that foster more consistent practice of the art of medicine.He called these behaviors “ HYPERLINK "http://www.aafp.org/fpm/2014/0700/p25.html" l "fpm20140700p25-bt1" The Magnificent Seven ” and they have been nicely summarized below for a better understanding of what goes around in the consultation room:

1. Preparation – Before entering the consultation room, doctors usually need a moment to personally prepare for the encounter. This will set the stage for all that is to follow. They should be aware of what is going on in their own body and mind, whether they are feeling rushed or tense or are still thinking about the previous patient. If so, it is advisable to take a deep breath or even have a coffee break to let go of the tension or preoccupation so that it is not carried into the next encounter.

Then, focus should be on the patient infront of you. What do you know about him or her? Where are you in terms of developing your relationship? What would you like to learn about this person that you don't already know? What is the topic of the encounter, if known, and how might that drive what needs to be accomplished during the consultation? Becoming mindful of these details outside the consultation room is a precursor to being mindful inside the consultation room. Nothing personal!

2. Establishment of rapport – The first few minutes of the consultation are usually dedicated to connecting with the patient, even before opening the records. Connection occurs on at least two levels; interpersonal and intellectual. Interpersonal contact is aimed at developing rapport and generally begins by incorporating a short, non-medical social interaction to open the interview. This is a good time to get to know a bit more about the patient.

A good tactic that most doctors usually use is to refer to something mentioned in prior consultations as a way to reinforce the continuity of their relationship with the patient, such as “So how is your dog doing?” or “How is your garden coming along?”. These are purely and clearly non-medical questions but they often help the doctor find clues about their patient’s current emotional state.

Spending a small amount of time socializing with and listening to the patient is worth the investment, as it has been shown to yield higher patient satisfaction. The intellectual aspect of connection signals that a doctor is transitioning from the social/rapport-building aspects of the interview to the medical aspects. This usually involves taking time in addressing the most important reason for the visit and offering assurance.

3. Smile a lot (my personal favourite) – Medicine is a serious business, and doctors are seriously busy people but if one is too serious or too busy for comfort they are missing out on something powerful. Similing and a bit of humor can be helpful in establishing rapport, relieving anxiety, communicating messages and caring, enhancing healing, and providing an acceptable outlet for anger and frustration.  It has generally favorable physiological effects too but, like any other tool, it should be used appropriately and not be a consulation spoiler.

4. Good communication –  Renowned Psychologist Carl Rogers suggested that those who counsel patients need to display three things in their communication: Congruence (being authentic and letting the patient experience who you really are, instead of putting on a facade), Acceptance (showing that you value the person even if you don't agree with his or her thoughts or actions), Empathy (relating and being sensitive to what the patient is experiencing).


Rogers' research indicated that individuals exposed to a relationship with high degrees of these qualities grew in their potential. Patients who have problems of living (such as domestic problems, socioeconomic challenges, or emotional issues) that present as medical problems can be particularly difficult to communicate with and are often labeled “difficult patients.” Managing them will require a doctor to use two skills that can be uncomfortable.

The first is relational immediacy, that is, the ability to communicate about a dynamic or behavior that is happening in the present moment of the encounter (e.g., “I'm feeling frustrated, and I'm sensing that you are too. Can we start over?”). The other skill a doctor needs is to put their foot down and confront. This is one of the most powerful actions a doctor can take to make a change in a patient’s life because it focuses on areas that need  change. However, confrontation can trigger volatile, defensive reactions from patients if not applies with caution.

5. Being mindful – The diagnosis and treatment of a patient's illness is a core medical function, but what is more important is the impact of the illness and suffering on the patient’s daily life. Patient suffering is more than just physical pain. It is “the state of severe distress associated with events that threaten the intactness of the person.”

In other words, it affects their personhood. To assess a patient's suffering, doctors usually dwell on the patient’s profession, support structure, personal beliefs, spirituality, religion etc. These may seem irrelevant when asked by they all fit into the equation.

6. The power of touch – A general rule in medicine is to always touch the part that’s hurting, but never to touch the part that hurts first. A warm handshake or a pat on the shoulder usually helps calm distraught or anxious patients, and touch has also been associated with health benefits like pain relief.

However it is always advisable to use touch cautiously as some patients’ reactions may be unpredictable especially those who have been physically or sexually abused, patients who are psychiatrically or developmentally challenged, and patients who are seductive. Also, doctors need  be culturally sensitive. Full explaination detailing what the physical examination entails should be offered and permission sought before the actual examination.

7. Showing some empathy – As discussed earlier, psychologist Carl Rogers included empathy, as an important ingredient in communication. Empathy is described as putting yourself in the patient’s shoes and sensing their world “as if it were your own”. This attempt to understand the patient's experience not only helps to establish a caring relationship but also can affect physiological results. For example, patients with highly empathetic physicians have been shown to have a shorter course of cold symptoms and better glycemic (diabetes) control than those whose physicians are less empathetic.

The hospital is an environment in which physicians find themselves increasingly overwhelmed, burnt out and disillusioned. Utilizing the tactics above may help minimize the tension between the patient and the doctor and deepen their relations. There might be a lot of changes to existing perspectives, perceptions, connections and experiences altogether. For comments or questions please email agboima@yahoo.com.

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Technology saves Lions from angry Okavango villagers

22nd November 2022

Villagers in the eastern Okavango region are now using an alert system which warns them when collared lions approach livestock areas. The new technology is now regarded as a panacea to the human/wildlife conflict in the area as it has reduced mass poisoning and killing of lions by farmers.

The technology is being implemented by an NGO, Community Living Among Wildlife Sustainably (CLAWS) within the five villages of Seronga, Gunutsoga, Eretsha, Beetsha and Gudigwa in the eastern part of the Okavango delta.

A Carnivore Ecologist from CLAWS, Dr Andrew Stein explained that around 2013, villagers in the eastern Okavango were having significant problems with losses of their cattle to predators specifically lions, so the villagers resorted to using poison and shooting the lions in order to reduce their numbers.

He highlighted that as a form of progressive intervention, they designed a programme to reduce the conflicts and promote coexistence. Another component of the programme is communal herding, introduced in 2018 to reduce the conflict by increasing efficiency whereby certified herders monitor livestock health and protect them from predators, allowing community members to engage in other livelihood activities knowing that their livestock are safe.

They are now two herds with 600 and 230 cattle respectively with plan to expand the programme to other neighbouring villages. Currently the programme is being piloted in Eretsha, one of the areas with most conflict incidences per year.

Dr Stein explained that they have developed the first of its kind alert system whereby when the lions get within three or five kilometers of a cattllepost or a homestead upon the five villages, then it will release an alert system going directly to the cellphones of individuals living within the affected area or community.

‘So, if a colored lion gets to about five kilometers of Eretsha village or any villagers in the Eretsha that has signed up for, the system will receive an SMS of the name of the lion and its distance to or from the village”, he stated. He added that this enables villagers to take preventative action to reduce conflicts before its starts.

Dr Stein noted that some respond by gathering their cattle and put them in a kraal or put them in an enclosure making sure that the enclosure is secure while some people will gather firewood and light small fires around edges of the kraal to prevent lions from coming closer and some when they receive the SMS they send their livestock to the neighbours alerting them about the presence of lions.

He noted that 125 people have signed to receive the alert system within Seronga, Eretsha, Beetsha, Gunutsoga and Gudigwa. He added that each homestead is about five people and this means more than 600 people immediately receive the messages about lions when they approach their villages. He also noted that last year they dispersed over 12 000 alerts, adding that this year is a bit higher as about 20 000 alerts have been sent so far across these villages.

Stein further noted that they have been significant changes in the behavior of the villagers as they are now tolerant to lions. “85 percent were happy with the SMS and people are becoming more tolerant with living with lions because they have more information to reduce the conflicts,” he stressed.

Stein noted that since the start of the programme in 2014 they have seen lion populations rebounds almost completely to a level before and they have not recorded cases of lion poisoning in the last three years which is commendable effort.

Monnaleso Sanga from Eretsha village applauded the programme by CLAWS noting that farmers in the area are benefiting through the alert system and take preventative measures to reduce human/lion conflict which has been persistent in the area. He added that numbers of cattle killed by lions have reduced immensely. He also admitted that they are now tolerant to lions and they no longer kill nor poison them.

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THE IDEAL QUALITY OF A MUSLIM

8th September 2022

A Muslim is supposed to be and should be a living example of the teachings of the Quran and the ‘Sunnah’ (the teachings and living examples of Prophet Muhammed (SAW – Peace be upon Him). We should follow these in all affairs, relations, and situations – starting with our relationship with our Lord, our own self, our family and the people around us. One of the distinguishing features of the (ideal) Muslim is his faith in Allah, and his conviction that whatever happens in the universe and whatever befalls him, only happens through the will and the decree of the Almighty Allah.

A Muslim should know and feel that he is in constant need of the help and support of Allah, no matter how much he may think he can do for himself. He has no choice in his life but to submit to the will of his Creator, worship Him, strive towards the Right Path and do good deeds. This will guide him to be righteous and upright in all his deeds, both in public and in private.

His attitude towards his body, mind and soul

The Muslim pays attention to his body’s physical, intellectual and spiritual needs. He takes good care of his body, promoting its good health and strength. He shouldn’t eat in excess; but he should eat enough to maintain his health and energy. Allah, The Exalted, Says “…Eat and drink; but waste not by excess, for Allah loves not the wasters.” [Quran 7: 31]

The Muslim should keep away from alcohol and drugs. He should also try to exercise regularly to maintain his physical fitness. The Muslim also keeps his body and clothes clean, he bathes frequently. The Prophet placed a great emphasis on cleanliness and bathing. A Muslim is also concerned with his clothing and appearance but in accordance with the Islamic ideal of moderation, avoiding the extremes.

As for his intellectual care, the Muslim should take care of his mind by pursuing beneficial knowledge. It is his responsibility to seek knowledge whether it is religious or secular, so he may understand the nature and the essence of things. Allah Says: “…and say: My Lord! Increase me in knowledge.” [Quran 20: 114

The Muslim should not forget that man is not only composed of a body and a mind, but that he also possesses a soul and a spirit. Therefore, the Muslim pays as much attention to his spiritual development as to his physical and intellectual development, in a balanced manner which ideally does not concentrate on one aspect to the detriment of others.

His attitude towards people

The Muslim must treat his parents with kindness and respect, compassion, politeness and deep gratitude. He recognizes their status and knows his duties towards them. Allah Says “And serve Allah. Ascribe nothing as partner unto Him. (Show) kindness unto parents…” [Quran 4: 36]

With his wife, the Muslim should exemplify good and kind treatment, intelligent handling, deep understanding of the nature and psychology of women, and proper fulfilment of his responsibilities and duties.

With his children, the Muslim is a parent who should understand his responsibility towards their good upbringing, showing them love and compassion, influence their Islamic development and giving them proper education, so that they become active and constructive elements in society, and a source of goodness for their parents, community, and society as a whole.

With his relatives, the Muslim maintains the ties of kinship and knows his duties towards them. He understands the high status given to relatives in Islam, which makes him keep in touch with them, no matter what the circumstances.

 

With his neighbours, the Muslim illustrates good treatment, kindness and consideration of others’ feelings and sensitivities. He turns a blind eye to his neighbour’s faults while taking care not to commit any such errors himself. The Muslim relationship with his wider circle of friends is based on love for the sake of Allah. He is loyal and does not betray them; he is sincere and does not cheat them; he is gentle, tolerant and forgiving; he is generous and he supplicates for them.

In his social relationships with all people, the Muslim should be well-mannered, modest and not arrogant. He should not envy others, fulfils his promises and is cheerful. He is patient and avoids slandering and uttering obscenities. He should not unjustly accuse others nor should he interfere in that which does not concern him. He refrains from gossiping, spreading slander and stirring up trouble – avoids false speech and suspicion. When he is entrusted with a secret, he keeps it. He respects his elders. He mixes with the best of people. He strives to reconcile between the Muslims. He visits the sick and attends funerals. He returns favours and is grateful for them. He calls others to Islam with wisdom, example and beautiful preaching. He should guide people to do good and always make things easy and not difficult.

The Muslim should be fair in his judgments, not a hypocrite, a sycophant or a show-off. He should not boast about his deeds and achievements. He should be straightforward and never devious or twisted, no matter the circumstances. He should be generous and not remind others of his gifts or favours. Wherever possible he relieves the burden of the debtor. He should be proud and not think of begging.

These are the standards by which the (ideal) Muslim is expected to structure his life on. Now how do I measure up and fit into all this? Can I honestly say that I really try to live by these ideals and principles; if not can I really call myself a true Muslim?

For the ease of writing this article I have made use of for want of a better word, the generic term ‘he’, ‘his’, ‘him’ and the ‘male’ gender, but it goes without saying that these standards apply equally to every female and male Muslim.

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OUR BELOVED CHILDREN

29th August 2022

“Homicide and suicide kill almost 7000 children every year; one in four of all children are born to unmarried mothers, many of whom are children themselves…..children’s potential lost to spirit crushing poverty….children’s hearts lost in divorce and custody battles….children’s lives lost to abuse and violence, our society lost to itself, as we fail our children.” “If you bungle raising your children, I don’t think whatever else you do matters very much.” (Quotation taken from a book written by Hillary Clinton).

These words may well apply to us here in Botswana; We are also experiencing a series of challenges in many spheres of development and endeavour but none as challenging as the long term effects of what is going to happen to our youth of today. One of the greatest challenges facing us as parents today is how to guide our youth to become the responsible adults that we wish them to be, tomorrow.

In Islam Prophet Muhammad (PBUH) has enjoined upon the parents to take care of the moral and religious instruction of their children from the very beginning, otherwise they will be called to account for negligence on the Day of Judgement. Parents must inculcate God-consciousness in their children from an early age, whereby the children will gain an understanding of duty to The Creator.

 

The Holy Qur’an says: ‘O you who believe! Save yourself and your families from the Fire of Hell’. (Ch. 66: V6). This verse places the responsibility on the shoulders of the parents to ensure that training and guidance begin at home. The goal is to mould the child into a solid Islamic personality, with good morals, strong Islamic principles, knowledge and behavior so as to be equipped to face the demands of life in a responsible and mature manner. This should begin with the proper environment at home that inculcates the best moral and behavioral standards.

But what do we have instead? Believers of all Religious persuasions will agree that we have children growing up without parental guidance, a stable home environment, without role models, being brought up in surroundings that are not conducive to proper upbringing and moulding of well-adjusted children. These children are being brought up devoid of any parental guidance and increasingly the desperate situation of orphaned children having to raise their siblings (children raising children) because their parents have succumbed to the scourge of AIDS.

It is becoming common that more and more girls still in their schooling years are now falling pregnant, most of them unwanted, with the attendant responsibilities and difficulties.

Observe the many young ladies who are with children barely in their teens having illegitimate children. In the recent past there was a campaign focused on the ‘girl-child’; this campaign targeted this group of young females who had fallen pregnant and were now mothers. The situation is that the mother still being just a ‘child’ and not even having tasted adulthood, now has the onerous responsibility of raising her own child most of the time on her own because either the father has simply disappeared, refuses to takes responsibility, or in some cases not even known.

We cannot place the entire blame on these young mothers; as parents and society as a whole stand accused because we have shirked our responsibilities and worse still we ourselves are poor role models. The virtual breakdown of the extended family system and of the family unit in many homes means that there are no longer those safe havens of peace and tranquility that we once knew. How then do we expect to raise well-adjusted children in this poisoned atmosphere?

Alcohol has become socially acceptable and is consumed by many of our youth and alarmingly they are now turning to drugs. Alcohol is becoming so acceptable that it is easily accessible even at home where some parents share drinks with their children or buying it for them. This is not confined only to low income families it is becoming prevalent amongst our youth across the board.

 

It is frightening to witness how our youth are being influenced by blatantly suggestive pop culture messages over television, music videos and other social media. Children who are not properly grounded in being able to make rational and informed decisions between what is right and what is wrong are easily swayed by this very powerful medium.

 

So what do we do as parents? We first have to lead by example; it is no longer the parental privilege to tell the child ‘do as I say not as I do’- that no longer works. The ball is in the court of every religious leader (not some of the charlatans who masquerade as religious leaders), true adherents and responsible parents. We cannot ignore the situation we have to take an active lead in guiding and moulding our youth for a better tomorrow.

In Islam Prophet Muhammad (pbuh) said: “No father gives a better gift to his children than good manners and good character.”  Children should be treated not as a burden, but a blessing and trust of Allah, and brought up with care and affection and taught proper responsibilities etiquettes and behaviour.

Even the Bible says; ‘Suffer the little children to come unto me and forbid them not, for of such is the kingdom of God. Verily I say unto you, whosoever shall not receive the kingdom of God as a little child, he shall not enter therein’. (Mark 10:14-15)

The message is clear and needs to be taken by all of us: Parents let us rise to the occasion – we owe it to our children and their future.

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