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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 possibly 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.

 

It is not unusual in our profession to ask questions, lots of questions! Some of which may 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 is infront of us; nothing personal! We rely largely on the history and the cooperation (or lack therof) of the patients or guardians to give us reliable answers in order to make diagnoses.

 

The rule is; unless and until we ask, we wont know and we wont be able to give the right treatment. 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". So 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.

What was evident from the debate was 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, dealing with difficult patients, and what physicians find meaningful in their work. 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 “ The Magnificent Seven ” and they have been nicely summarized in this article for a better understanding of what goes on 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 psychologican or 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 addressingthe 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. Smiling 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 been shown to have favorable physiological effects too but, like any other tool, it should be used appropriately and not be allowed to spoil the consulation.


4. Good communication-  Renowned Psychologist Carl Rogers suggested that those who counsel patients need to display three things in their communication for it to be considered good:


Congruence (being authentic and letting the patient experience who they 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 we often label them “difficult patients.” Managing them will require a doctor to use the above tactics and even additional ones that might not be popular with patients like confrontation. Confrontation 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 applied 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 social aspect; the impact of the illness and suffering on the patient’s daily life. Patient suffering can be more than just physical pain; it can affect 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. If a doctor is just about to do physical examination, full explanation detailing what it entails should be offered and permission sought before the actual examination is carried out.


7. Showing some empathy – As discussed earlier, psychologist Carl Rogers included empathy, as an important ingredient in communication. It also makes an important part of the art of medicine. 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. Yes, we do feel pain for our patients and it is absolutely normal to show it contrary to the belief that it is a sign of cowardice and a good doctor is the one who is desensitized from what is happening to his/her patients.

The hospital is an environment in which physicians find themselves increasingly overwhelmed, burnt out and disillusioned. Utilizing the tactics above can help minimize the tension between the patient and the doctor and deepen their relations. These may also bring 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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Parricide at Herod’s Court

25th January 2021
SAILI

A wife, uncle, and two in-laws fall at the hands of Judah’s despot

The pre-eminent Jewish chronicler, Flavius Josephus, said of Herod the Great that he was “blessed with every gift of looks, body, and mind” but he was a “slave to his passions”. This was in the context of a gloating bloodlust.

His sword knew no sacred cows: neither his own kids, wives, in-laws, next of kin, nor bosom friends were immune from it. He is on record as pestering Caesar Augustus with a barrage of letters seeking permission to execute his own flesh and blood, prompting the Roman emperor to at one time quip that, “It is better to be Herod’s pig than his son”, which was apt: as a “Jew”, Herod did not eat pork and therefore in the event that he kept any pigs, they would never have to be killed.

You are by now well-apprised of the death of Hyrcanus II by the same Herod, General Atiku, in 30 BC. Hyrcanus, a Hasmonean ruler of Judah twice over, was actually the grandfather of Mariamne I, Herod’s most beloved wife and his second of up to 10 wives. It was Mariamne’s own mother Salome, who dreading Herod’s pathological savagery, pitched Mariamne to Herod in the hope that that would insure her family from Herod’s murderous caprices.

Now, Mariamne, General, was as much a stunning beauty as her younger brother Aristobulus III was breathtakingly good-looking. Having tied the knot with Herod in 37 BC, Mariamne had prevailed over her husband to install Aristobulus as High Priest. The post had fallen vacant on the death of Antigonus in 37 BC and Herod had appointed one Ananel, who had no ties whatsoever to the Hasmoneans, the first such in more than a century, in his place. Unable to resist the spirited entreaties of his beloved wife, who had also lobbied Queen Cleopatra of Egypt and her beau Mark Anthony, Herod gave in and replaced Ananel with Aristobulus, who was only 16 years old, in 36 BC.

Because of his enormous charisma and overall affability, Aristobulus was a hit with the masses despite his tender age and Herod was envious of the young man’s rock star-like popularity. To make doubly sure the young man did not harbour a seditious ace up his sleeve, the morbidly paranoid Herod had his spooks watch on both Aristobulus and his mother round the clock. Sensing imminent danger, Aristobulus contacted Cleopatra, asking for a pre-emptive safe passage to Egypt and there enjoy absolute freedom. When Herod got wind of this, he decided to get rid of Aristobulus as he did not wish him to be a perennial thorn in his flesh from the utter safety of self-imposed exile.

The opportunity came at a banquet in Jericho which was organised by Aristobulus’ mother. There, Herod had one of his henchmen cause Aristobulus to drown during a dusk time horseplay in a swimming pool. Of course Herod would forever maintain the drowning was accidental when everybody knew it was in truth a tactical elimination. Poor Aristobulus was only 17 years old having been born in 56 BC. He was the last Hasmonean High Priest and was replaced by the previously deposed Ananel, who was to remain in that position till 29 BC.

HEROD ACQUITTED OVER THE ARISTOBULUS DEATH

It need not be over-emphasised, General, that Mariamne and her mother Alexandra did not take Herod’s line over the all too untimely demise of Aristobulus lying down. If he had reckoned that with the death of Aristobulus he had gotten rid of potentially the most potent threat to his omnipotence, he was totally mistaken. Herod had actually simply fanned the flames of intrigue against him, for mother and daughter confronted him and accused him of murdering their boy in cold blood.

Nor did the two Iron Ladies end matters there: Alexandra wrote a lachrymal letter to Cleopatra to get her to bring her influence to bear on Mark Anthony so that Herod paid dearly and likewise for his nefarious act. Anthony, who at the time was the Roman colossus in charge of the whole of the Middle East, was persuaded and during a visit to Laodicea (in modern-day Turkey, though some accounts say it was Rhodes in Cyprus), he commanded Herod to report to him forthwith and exculpate himself over the affair.

Although Herod put a brave face on the matter, General, he was rather unsure of his eventual fate after the trial. He also suspected rightly or wrongly that Anthony had a thing for the voluptuously beautiful Mariamne and the last thing Herod wanted was for any other man to bed his beloved Mariamne even in death. So before he set off for Laodicea, Herod instructed his uncle Joseph, who was married to his sister Salome, to make sure that in the event that Anthony sentenced him to death, he should immediately put her to the sword. He also detailed a certain Sohemus, a most trusted aide, to stand sentry over the entire womenfolk at the palace.

Herod, however, had the nine lives of a cat, General. Using his immense rhetorical skills and the time-honoured palm greasing, he won himself an acquittal. Meanwhile, the Judean rumourville was abuzz with chatter that Herod had been summarily executed by Anthony, as a result of which people became spendthrifts of their tongues.

Both Joseph and Sohemus disclosed to Mariamne the instructions Herod had left them with in relation to her fate once he was no more. Mariamne was both livid and distraught that her husband regarded her as so easily expendable when outwardly he cherished her beyond words. To her mind, his arrangements with Joseph had nothing to do with love but sprang from sheer monstrosity. She probably thanked God that he was dead, but the fact of the matter was that he was not and when he at long last turned up, she did not want to have anything to do with him, including the conjugation which he so eagerly pined for after such an extended absence.

HEROD KILLS HIS WIFE AND HIS UNCLE

Now, if Herod had a kind of Svengali, General, it was his youngest sister Salome. Salome (65 BC-10 AD) was the most powerful woman at Herod’s court. A sly, scheming, and manipulating vixen, she arguably more than any other living being had the most sway in a negative sense on her brother, who took practically whatever she said as gospel truth.

Let us nevertheless, General, take stock of the fact that the bulk of what we learn about Salome comes from Flavius Josephus, who himself relied on the writings of Herod’s court historian Nicolaus of Damascus. For one reason or the other, Nicolaus did not see eye to eye with Salome and it is therefore possible that much of what Nicolaus relates of her is embellished to smear her before the court of history.
Upon his return, Herod was told of the rumours of his death and so was surprised to find Mariamne alive when Joseph and Sohemus should in the circumstances have had her killed if indeed they were loyal to him. In fact, Joseph had even put Mariamne and Alexandra into the safe custody of Roman legions stationed in Judea just in case Jewish malcontents who abhorred Herod turned their wrath on them.

But there was more. Salome reported to Herod that Mariamne, who she hated like the plague, had had sexual relations with both Joseph and Sohemus, this being Mariamne’s reward to them for dishing out to her the dirt on Herod, and that she had on several occasions before attempted to poison him. Now, no one would hump Herod’s most beloved wife and get away scotfree. It is therefore small wonder that Herod straightaway ordered the execution of Joseph and Sohemus. Joseph was 61 years old at the time of his death in 34 BC, having been born in 95 BC. In the case of Mariamne herself though, he had her subjected to a formal court trial not on charges of adultery but of attempted regicide.

Herod had hoped that the court would acquit her, whereupon he would make bygones be bygones so great was his love for the woman, but sadly for him, General, she was found guilty and sentenced to death. Even then, Herod tactfully dilly-dallied on signing the writ of execution and simply had his wife detained at a fortress for some time until Salome prevailed over him to execute her at long last. Writes Josephus: “Thus, with the death of the noble and lovely Mariamne ended the glorious history of the Hasmonean High Priest Mattathias and his descendants.”

For a long time to come though, General, Herod was haunted by the death of his wife to the point of even sometimes coming across as if he had lost his mind. “When Herod realised what this meant (the death sentence passed on Mariamne), he tried in vain to have the verdict changed, but Salome did not rest until the death penalty was carried out,” Josephus informs us. “Herod was heartbroken; nothing could comfort him for the loss of his lovely wife.

For seven years he refused to have her body buried, and held it, embalmed, in his palace. Afterwards, he became so melancholy and despondent, nothing interested him or could arouse any enthusiasm in him for living … He was so far conquered by his passion, that he would order his servants to call for Mariamne, as if she were still alive, and could still hear them … He tried hard to forget his trouble by going hunting and banqueting, but nothing helped. Herod built new cities and erected temples and palaces. He also named a tower in honour of Mariamne.”

HEROD SLAYS SISTER’S EX-HUBBY

Mariamne’s death was not the only one which Herod perpetrated through the instrumentality of Salome. There were actually several and included those of her own husband Costobarus. Salome was married four times, to her uncle Joseph (45 BC); Costobarus (34 BC); Sylleus (circa 27 BC); and Alexas (20 BC).

Like the Herod clan, Costobarus was of Idumean stock. It was Costobarus Herod had made governor of Idumea and Gaza and upon Joseph’s death had him tie the knot with Salome, with the couple eventually siring two children, Berenice and Antipater III. Costobarus, though, soon began to harbour monarchical ambitions of his own and wrote to Cleopatra beseeching her to persuade Mark Anthony to make Idumea independent of Herod and install him (Costobarus) as Rome’s client King of the territory.

Of course upon learning of this, Herod was not amused. It was Salome who pleaded with him not to put her husband to the sword. Next time, however, a dumped Costobarus was not so lucky. Seven years after their marriage, Salome and Costobarus parted ways and a possibly hurt Salome decided to exact vengeance. She informed her brother that he had been harbouring two fugitives from Herodian justice for a full 12 years at his own farm.

The two were simply known as the Sons of Baba. Baba ben Babuta, their father and clan patriarch, was related to the Hasmonean ruler Antigonus, who Herod had replaced and killed in 37 BC with the help of Roman legions. Baba and his sons had resisted Herod at the time, with his sons henceforth persisted in insurrectionist activity against Herod. Baba himself had been captured and blinded by Herod but spared anyway as he no longer posed any threat. Writes Josephus: “Now the Sons of Babas were of great dignity, and had power among the multitude, and were faithful to Antigonus, and were always raising calumnies against Herod, and encouraged the people to preserve the government to that royal family (the Hasmoneans) which held it by inheritance.”

Costobarus had provided the Sons of Baba an indefinite lair “supposing that their preservation might be of great advantage to him in the changes of government afterward”. Following the Salome tip, Herod had Costobarus and the Sons of Baba summarily executed “so that none was left alive of the family of Hyrcanus (the Hasmonean), and the kingdom was wholly in Herod’s power, there being no one of high rank to stand in the way of his unlawful acts” per Josephus.

NEXT WEEK: HEROD’S WRATH ON HIS OWN SONS

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WHAT’S UP WITH WHATSAPP?

25th January 2021

In early January, WhatsApp, part of Facebook Inc., began alerting its 2 billion users to an update of its privacy policy which, should they want to keep using the popular messaging app, they have to accept. Much of the policy, which is about commercialising WhatsApp, states ‘WhatsApp receives information from, and shares information with, the other Facebook Companies.

We may use the information we receive from them, and they may use the information we share with them, to help operate and market services’. WhatsApp is now reserving the right to share data it collects about you with the broader Facebook network, which includes Instagram, regardless of whether you have accounts or profiles there, claiming it needs it to help operate and improve its offerings. More broadly, almost all of the $21.5 billion in revenues which Facebook generated in the third quarter of 2020 came from advertising and there is currently none in WhatsApp.

The company now wants to be able to serve more targeted ads to people on Facebook and Instagram by also garnering their usage habits on WhatsApp and enabling businesses take payments via WhatsApp for items that were selected on other Facebook sites. For long-time users, the option to share data with Facebook was made available in 2016, but it was just that: optional and temporary. It was now to become mandatory for everybody from Feb. 8 but owing to a massive backlash, the company has delayed that to May 15 to try and persuade users to sign up to the new Ts and Cs.

WhatsApp on Monday attempted to address the uproar over privacy concerns with a post on its website, explaining that the update was designed to aid businesses on its platform, as it reiterated in Friday’s post.

“We want to be clear that the policy update does not affect the privacy of your messages with friends or family in any way. Instead, this update includes changes related to messaging a business on WhatsApp, which is optional, and provides further transparency about how we collect and use data.”

These new terms have caused an outcry among technology experts, privacy advocates, billionaire entrepreneurs and government organisations and triggered a wave of defections to rival services. Elon Musk has urged his followers to switch to Signal and the governments of Turkey and India have threatened to block the app if it insists on proceeding.

‘WhatsApp’s updated privacy policy verges on user surveillance and threatens India’s security’, a petition filed in an Indian court said on Thursday, presenting another legal challenge for the Facebook Inc. -owned messenger. “It virtually gives a 360-degree profile into a person’s online activity,” lawyer Chaitanya Rohilla told the Delhi High Court. Many Indian users have began installing rival apps like Signal and Telegram, pushing WhatsApp to begin a costly advertising campaign to calm its 400 million customer-base, the largest of any country. The change has also met with a challenge in Turkey with the country’s Competition Board this week launching an investigation into the messaging service and its parent company.

Elsewhere too, in spite of Whatsapp protestations, millions of its users are already migrating to alternative platforms. Signal saw 7.5 million downloads last week,  a 4,200% spike since the previous week and large swaths of users also jumped to Telegram, as the platform gained 9 million new users last week, up 91% from the previous week. Both apps are now topping Google and Apple’s app stores,

Facebook could possibly learn a lesson from history here. Every past empire – Aztec, Mayan, Greco-Roman, Sumerian, Mongol, Chinese, Ottoman and more recently British, all saw their star rise, their glory swell, their boundaries grow and yet each eventually fell, often the instigators of their own downfall.

They expanded too far too fast and could not control what they had initially conquered. And now it looks like the same fate might await this large tech giant. Parent company Facebook has also come under fire recently for overt and covert censorship policies with questions raised as to partisanship and curtailment of freedom of speech. Thus one would have to question the wisdom of the timing of this new Whatsapp privacy policy, if nothing else.

To understand its influence and control one only has to check out the un-smart sector of the mobile phone industry which for some time has offered handsets a small step up from the basic starter sets with Facebook and Whatsapp as default screen app settings. These limited internet access options have allowed millions of users to connect with affordable data bundle packages.

And for Google smartphone subscribers, the search engine automatically connects its base to Whatsapp and Facebook – one big, happy family. Facebook is also seamlessly linked to Paypal offering contact-less charges for its boosted post advertising, a somewhat sinister partnership which accesses their Paypal log-in and authorisation details without the need to inform the payee – the transaction is simply deducted automatically from the registered credit card. This is Big Brother with a blue logo.

The bottom line here is that if you have any privacy issues at all – and you probably should – you might as well make the switch now before you are forced to sign away your rights in May. And the plus part is that both Signal and Telegram have the technological edge over Whatsapp anyway, the latter even being accessible on multiple platforms simultaneously, not just on your phone.
Empires take time to crumble and Facebook is not in imminent danger but information is a weapon that can be used in any war, even a virtual conflict, so don’t give this giant any more ammunition than it already has.

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The Daring Dozen at Bari

8th December 2020
JEFF---Batswana-smoke-unit

Seventy-seven years ago, on the evening of December 2, 1943, the Germans launched a surprise air raid on allied shipping in the Italian port of Bari, which was then the key supply centre for the British 8th army’s advance in Italy.

The attack was spearheaded by 105 Junkers JU88 bombers under the overall command of the infamous Air Marshal Wolfram von Richthofen (who had initially achieved international notoriety during the Spanish Civil War for his aerial bombardment of Guernica). In a little over an hour the German aircraft succeeded in sinking 28 transport and cargo ships, while further inflicting massive damage to the harbour’s facilities, resulting in the port being effectively put out of action for two months.

Over two thousand ground personnel were killed during the raid, with the release of a secret supply of mustard gas aboard one of the destroyed ships contributing to the death toll, as well as subsequent military and civilian casualties. The extent of the later is a controversy due to the fact that the American and British governments subsequently covered up the presence of the gas for decades.

At least five Batswana were killed and seven critically wounded during the raid, with one of the wounded being miraculously rescued floating unconscious out to sea with a head wound. He had been given up for dead when he returned to his unit fourteen days later. The fatalities and casualties all occurred when the enemy hit an ammunition ship adjacent to where 24 Batswana members of the African Pioneer Corps (APC) 1979 Smoke Company where posted.

Thereafter, the dozen surviving members of the unit distinguished themselves for their efficiency in putting up and maintaining smokescreens in their sector, which was credited with saving additional shipping. For his personal heroism in rallying his men following the initial explosions Company Corporal Chitu Bakombi was awarded the British Empire Medal, while his superior officer, Lieutenant N.F. Moor was later given an M.B.E.

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