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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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Chronic Joblessness: How to Help Curtail it

30th November 2020
Motswana woman

The past week or two has been a mixed grill of briefs in so far as the national employment picture is concerned. BDC just injected a further P64 million in Kromberg & Schubert, the automotive cable manufacturer and exporter, to help keep it afloat in the face of the COVID-19-engendered global economic apocalypse. The financial lifeline, which follows an earlier P36 million way back in 2017, hopefully guarantees the jobs of 2500, maybe for another year or two.

It was also reported that a bulb manufacturing company, which is two years old and is youth-led, is making waves in Selibe Phikwe. Called Bulb Word, it is the only bulb manufacturing operation in Botswana and employs 60 people. The figure is not insignificant in a town that had 5000 jobs offloaded in one fell swoop when BCL closed shop in 2016 under seemingly contrived circumstances, so that as I write, two or three buyers have submitted bids to acquire and exhume it from its stage-managed grave.

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The Era of “The Diplomat”

30th November 2020
FATED “JIHADI” JOHN

Youngest Maccabees scion Jonathan takes over after Judas and leads for 18 years

Going hand-in-glove with the politics at play in Judea in the countdown to the AD era, General Atiku, was the contention for the priesthood. You will be aware, General, that politics and religion among the Jews interlocked. If there wasn’t a formal and sovereign Jewish King, there of necessity had to be a High Priest at any given point in time.

Initially, every High Priest was from the tribe of Levi as per the stipulation of the Torah. At some stage, however, colonisers of Judah imposed their own hand-picked High Priests who were not ethnic Levites. One such High Priest was Menelaus of the tribe of Benjamin.

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Land Board appointments of party activists is political corruption

30th November 2020

Parliament has rejected a motion by Leader of Opposition (LOO) calling for the reversing of the recent appointments of ruling party activists to various Land Boards across the country. The motion also called for the appointment of young and qualified Batswana with tertiary education qualifications.

The ruling party could not allow that motion to be adopted for many reasons discussed below. Why did the LOO table this motion? Why was it negated? Why are Land Boards so important that a ruling party felt compelled to deploy its functionaries to the leadership and membership positions?

Prior to the motion, there was a LOO parliamentary question on these appointments. The Speaker threw a spanner in the works by ruling that availing a list of applicants to determine who qualified and who didn’t would violate the rights of those citizens. This has completely obliterated oversight attempts by Parliament on the matter.

How can parliament ascertain the veracity of the claim without the names of applicants? The opposition seeks to challenge this decision in court.  It would also be difficult in the future for Ministers and government officials to obey instructions by investigative Parliamentary Committees to summon evidence which include list of persons. It would be a bad precedent if the decision is not reviewed and set aside by the Business Advisory Committee or a Court of law.

Prior to independence, Dikgosi allocated land for residential and agricultural purposes. At independence, land tenures in Botswana became freehold, state land and tribal land. Before 1968, tribal land, which is land belonging to different tribes, dating back to pre-independence, was allocated and administered by Dikgosi under Customary Law. Dikgosi are currently merely ‘land overseers’, a responsibility that can be delegated. Land overseers assist the Land Boards by confirming the vacancy or availability for occupation of land applied for.

Post-independence, the country was managed through modern law and customary law, a system developed during colonialism. Land was allocated for agricultural purposes such as ploughing and grazing and most importantly for residential use. Over time some land was allocated for commercial purpose. In terms of the law, sinking of boreholes and development of wells was permitted and farmers had some rights over such developed water resources.

Land Boards were established under Section 3 of the Tribal Land Act of 1968 with the intention to improve tribal land administration. Whilst the law was enacted in 1968, Land Boards started operating around 1970 under the Ministry of Local Government and Lands which was renamed Ministry of Lands and Housing (MLH) in 1999. These statutory bodies were a mechanism to also prune the powers of Dikgosi over tribal land. Currently, land issues fall under the Ministry of Land Management, Water and Sanitation Services.

There are 12 Main Land Boards, namely Ngwato, Kgatleng, Tlokweng, Tati, Chobe, Tawana, Malete, Rolong, Ghanzi, Kgalagadi, Kweneng and Ngwaketse Land Boards.  The Tribal Land Act of 1968 as amended in 1994 provides that the Land Boards have the powers to rescind the grant of any rights to use any land, impose restrictions on land usage and facilitate any transfer or change of use of land.

Some land administration powers have been decentralized to sub land boards. The devolved powers include inter alia common law and customary law water rights and land applications, mining, evictions and dispute resolution. However, decisions can be appealed to the land board or to the Minister who is at the apex.

So, land boards are very powerful entities in the country’s local government system. Membership to these institutions is important not only because of monetary benefits of allowances but also the power of these bodies. in terms of the law, candidates for appointment to Land Boards or Subs should be residents of the tribal areas where appointments are sought, be holders of at least Junior Certificate and not actively involved in politics.  The LOO contended that ruling party activists have been appointed in the recent appointments.

He argued that worse, some had no minimum qualifications required by the law and that some are not inhabitants of the tribal or sub tribal areas where they have been appointed. It was also pointed that some people appointed are septuagenarians and that younger qualified Batswana with degrees have been rejected.

Other arguments raised by the opposition in general were that the development was not unusual. That the ruling party is used to politically motivated appointments in parastatals, civil service, diplomatic missions, specially elected councilors and Members of Parliament (MPs), Bogosi and Land Boards. Usually these positions are distributed as patronage to activists in return for their support and loyalty to the political leadership and the party.

The ruling party contended that when the Minister or the Ministry intervened and ultimately appointed the Land Boards Chairpersons, Deputies and members , he didn’t have information, as this was not information required in the application, on who was politically active and for that reason he could not have known who to not appoint on that basis. They also argued that opposition activists have been appointed to positions in the government.

The counter argument was that there was a reason for the legal requirement of exclusion of political activists and that the government ought to have mechanisms to detect those. The whole argument of “‘we didn’t know who was politically active” was frivolous. The fact is that ruling party activists have been appointed. The opposition also argued that erstwhile activists from their ranks have been recruited through positions and that a few who are serving in public offices have either been bought or hold insignificant positions which they qualified for anyway.

Whilst people should not be excluded from public positions because of their political activism, the ruling party cannot hide the fact that they have used public positions to reward activists. Exclusion of political activists may be a violation of fundamental human or constitutional rights. But, the packing of Land Boards with the ruling party activists is clear political corruption. It seeks to sow divisions in communities and administer land in a politically biased manner.

It should be expected that the ruling party officials applying for land or change of land usage etcetera will be greatly assisted. Since land is wealth, the ruling party seeks to secure resources for its members and leaders. The appointments served to reward 2019 election primary and general elections losers and other activists who have shown loyalty to the leadership and the party.

Running a country like this has divided it in a way that may be difficult to undo. The next government may decide to reset the whole system by replacing many of government agencies leadership and management in a way that is political. In fact, it would be compelled to do so to cleanse the system.

The opposition is also pondering on approaching the courts for review of the decision to appoint party functionaries and the general violation of clearly stated terms of reference. If this can be established with evidence, the courts can set aside the decision on the basis that unqualified people have been appointed.

The political activism aspect may also not be difficult to prove as some of these people are known activists who are in party structures, at least at the time of appointment, and some were recently candidates. There is a needed for civil society organizations such as trade unions and political parties to fight some of these decisions through peaceful protests and courts.

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