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Friday, 01 December 2023

The art that is medicine

Columns

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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Columns

GONE FISHING

28th March 2023

In recent years, using personal devices in working environments has become so commonplace it now has its own acronym, BOYD (Bring Your Own Device).  But as employees skip between corporate tools and personal applications on their own devices, their actions introduce a number of possible risks that should be managed and mitigated with careful consideration.  Consider these examples:

Si-lwli, a small family-run business in Wales, is arguably as niche a company as you could find, producing talking toys used to promote the Welsh language. Their potential market is small, with only some 300,000 Welsh language speakers in the world and in reality the business is really more of a hobby for the husband-and-wife team, who both still have day jobs.  Yet, despite still managing to be successful in terms of sales, the business is now fighting for survival after recently falling prey to cybercriminals. Emails between Si-Iwli and their Chinese suppliers were intercepted by hackers who altered the banking details in the correspondence, causing Si-Iwli to hand over £18,000 (around P ¼ m) to the thieves. That might not sound much to a large enterprise, but to a small or medium business it can be devastating.

Another recent SMB hacking story which appeared in the Wall Street Journal concerned Innovative Higher Ed Consulting (IHED) Inc, a small New York start-up with a handful of employees. IHED didn’t even have a website, but fraudsters were able to run stolen credit card numbers through the company’s payment system and reverse the charges to the tune of $27,000, around the same loss faced by Si-Iwli.  As the WSJ put it, the hackers completely destroyed the company, forcing its owners to fold.

And in May 2019, the city of Baltimore’s computer system was hit by a ransomware attack, with hackers using a variant called RobinHood. The hack, which has lasted more than a month, paralysed the computer system for city employees, with the hackers demanding a payment in Bitcoin to give access back to the city.

Of course, hackers target governments or business giants  but small and medium businesses are certainly not immune. In fact, 67% of SMBs reported that they had experienced a cyber attack across a period of 12 months, according to a 2018 survey carried out by security research firm Ponemon Institute. Additionally, Verizon issued a report in May 2019 that small businesses accounted for 43% of its reported data breaches.  Once seen as less vulnerable than PCs, smartphone attacks are on the rise, with movements like the Dark Caracal spyware campaign underlining the allure of mobile devices to hackers. Last year, the US Federal Trade Commission released a statement calling for greater education on mobile security, coming at a time when around 42% of all Android devices are believed to not carry the latest security updates.

This is an era when employees increasingly use their smartphones for work-related purposes so is your business doing enough to protect against data breaches on their employees’ phones? The SME Cyber Crime Survey 2018 carried out for risk management specialists AON showed that more than 80% of small businesses did not view this as a threat yet if as shown, 67% of SMBs were said to have been victims of hacking, either the stats are wrong or business owners are underestimating their vulnerability.  A 2019 report by PricewaterhouseCoopers suggests the latter, stating that the majority of global businesses are unprepared for cyber attacks.

Consider that a workstation no longer means a desk in an office: It can be a phone in the back of a taxi or Uber; a laptop in a coffee shop, or a tablet in an airport lounge.  Wherever the device is used, employees can potentially install applications that could be harmful to your business, even from something as seemingly insignificant as clicking on an accidental download or opening a link on a phishing email.  Out of the physical workplace, your employees’ activities might not have the same protections as they would on a company-monitored PC.

Yet many businesses not only encourage their employees to work remotely, but assume working from coffee shops, bookstores, and airports can boost employees’ productivity.  Unfortunately, many remote hot spots do not provide secure Wi-Fi so if your employee is accessing their work account on unsecured public Wi-Fi,  sensitive business data could be at risk. Furthermore, even if your employee uses a company smartphone or has access to company data through a personal mobile device, there is always a chance data could be in jeopardy with a lost or stolen device, even information as basic as clients’ addresses and phone numbers.

BOYDs are also at risk from malware designed to harm and infect the host system, transmittable to smartphones when downloading malicious third-party apps.  Then there is ransomware, a type of malware used by hackers to specifically take control of a system’s data, blocking access or threatening to release sensitive information unless a ransom is paid such as the one which affected Baltimore.  Ransomware attacks are on the increase,  predicted to occur every 14 seconds, potentially costing billions of dollars per year.

Lastly there is phishing – the cyber equivalent of the metaphorical fishing exercise –  whereby  cybercriminals attempt to obtain sensitive data –usernames, passwords, credit card details –usually through a phoney email designed to look legitimate which directs the user to a fraudulent website or requests the data be emailed back directly. Most of us like to think we could recognize a phishing email when we see it, but these emails have become more sophisticated and can come through other forms of communication such as messaging apps.

Bottom line is to be aware of the potential problems with BOYDs and if in doubt,  consult your IT security consultants.  You can’t put the own-device genie back in the bottle but you can make data protection one of your three wishes!

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Columns

“I Propose to Diana Tonight”

28th March 2023

About five days before Princess Diana and Dodi Al Fayed landed in Paris, General Atiku, a certain Edward Williams was taking a walk in a woods in the Welsh town of Mountain Ash. Williams, then 73, was a psychic of some renown. He had in the past foretold assassination attempts on US President Ronald Reagan, which occurred on March 30, 1981, and Pope John Paul II, which came to pass on May 13, 1981.

As he trudged the woods, Williams  had a sudden premonition that pointed to Diana’s imminent fate as per Christopher Andersen’s book The Day Diana Died. “When the vision struck me, it was as if everything around me was obscured and replaced by shadowy figures,” Williams was later to reminisce. “In the middle was the face of Princess Diana. Her expression was sad and full of pathos. She was wearing what looked like a floral dress with a short dark cardigan. But it was vague. I went cold with fear and knew it was a sign that she was in danger.”

Williams hastily beat a retreat to his home, which he shared with his wife Mary, and related to her his presentiment, trembling like an aspen leaf as he did so. “I have never seen him so upset,” Mary recounted. “He felt he was given a sign and when he came back from his walk he was deeply shaken.”

The following day, Williams frantically sauntered into a police station to inform the police of his premonition. The officer who attended to him would have dismissed him as no more than a crackpot but he treated him seriously in view of the accuracy of his past predictions. He  took a statement and immediately passed it on to the Special Branch Investigative  Unit.

The report read as follows:

“On 27 August, at 14:12 hrs, a man by the name of Edward Williams came to Mountain Ash police station. He said he was a psychic and predicted that Princess Diana was going to die. In previous years, he has predicted that the Pope and Ronald Reagan were going to be the victims of assassination attempts. On both occasions he was proved to be correct. Mr Williams appeared to be quite normal.”

Williams, General, was spot-on as usual: four days later, the princess was no more.

Meanwhile, General,  even as Dodi and Diana were making their way to the Fayed-owned Ritz Hotel in central Paris, British newspapers were awash with headlines that suggested Diana was kind of deranged. Writes Andrew Morton in Diana in Pursuit of Love: “In The Independent Diana was described as ‘a woman with fundamentally nothing to say about anything’. She was ‘suffering from a form of arrested development’. ‘Isn’t it time she started using her head?’ asked The Mail on Sunday. The Sunday Mirror printed a special supplement entitled ‘A Story of Love’; The News of the World claimed that William had demanded that Diana should split from Dodi: ‘William can’t help it, he just doesn’t like the man.’ William was reportedly ‘horrified’ and ‘doesn’t think Mr Fayed is good for his mother’ – or was that just the press projecting their own prejudices? The upmarket Sunday Times newspaper, which had first serialised my biography of the princess, now put her in the psychiatrist’s chair for daring to be wooed by a Muslim. The pop-psychologist Oliver James put Diana ‘On the Couch’, asking why she was so ‘depressed’ and desperate for love. Other tabloids piled in with dire prognostications – about Prince Philip’s hostility to the relationship, Diana’s prospect of exile, and the social ostracism she would face if she married Dodi.”

DIANA AND DODI AT THE RITZ

Before Diana and Dodi departed the Villa Windsor sometime after 16 hrs, General, one of Dodi’s bodyguards Trevor Rees-Jones furtively asked Diana as to what the programme for the evening was. This Trevor did out of sheer desperation as Dodi had ceased and desisted from telling members of his security detail, let alone anyone else for that matter, what his onward destination was for fear that that piece of information would be passed on to the paparazzi. Diana kindly obliged Trevor though her response was terse and scarcely revealing. “Well, eventually we will be going out to a restaurant”, that was all Diana said. Without advance knowledge of exactly what restaurant that was, Trevor and his colleagues’ hands were tied: they could not do a recce on it as was standard practice for the security team of a VIP principal.  Dodi certainly, General, was being recklessly by throwing such caution to the winds.

At about 16:30, Diana and Dodi drew up at the Ritz Hotel, where they were received by acting hotel manager Claude Roulet.  The front entrance of the hotel was already crawling with paparazzi, as a result of which the couple took the precaution of using the rear entrance, where hopefully they would make their entry unperturbed and unmolested. The first thing they did when they were ensconced in the now $10,000 a night Imperial Suite was to spend some time on their mobiles and set about touching base with friends, relations, and associates.  Diana called at least two people, her clairvoyant friend Rita Rogers and her favourite journalist Richard Kay of The Daily Mail.

Rita, General,  was alarmed that Diana had proceeded to venture to Paris notwithstanding the warning she had given Dodi and herself in relation to what she had seen of him  in the crystal ball when the couple had consulted her. When quizzed as to what the hell she indeed was doing in Paris at that juncture, Diana replied that she and Dodi had simply come to do some shopping, which though partially true was not the material reason they were there. “But Diana, remember what I told Dodi,” Rita said somewhat reprovingly. Diana a bit apprehensively replied, “Yes I remember. I will be careful. I promise.” Well,  she did not live up to her promise as we shall soon unpack General.

As for Richard Kay, Diana made known to him that, “I have decided I am going to radically change my life. I am going to complete my obligations to charities and to the anti-personnel land mines cause, but in November I want to completely withdraw from formal public life.”

Once she was done with her round of calls, Diana went down to the hair saloon by the hotel swimming pool to have her hair washed and blow-dried ahead of the scheduled evening dinner.

THE “TELL ME YES” RING IS DELIVERED

Since the main object of their Paris trip was to pick up the “Tell Me Yes” engagement ring  Dodi had ordered in Monte Carlo a week earlier, Dodi decided to check on Repossi Jewellery, which was right within the Ritz prencincts, known as the Place Vendome.  It could have taken less than a minute for Dodi to get to the store on foot but he decided to use a car to outsmart the paparazzi invasion. He was driven there by Trevor Rees-Jones, with Alexander Kez Wingfield and Claude Roulet following on foot, though he entered the shop alone.

The Repossi store had closed for the holiday season but Alberto Repossi, accompanied by his wife and brother-in-law,  had decided to travel all the way from his home in Monaco  and momentarily open it for the sake of the potentially highly lucrative  Dodi transaction.  Alberto, however, disappointed Dodi as the ring he had chosen was not the one  he produced. The one he showed Dodi was pricier and perhaps more exquisite but Dodi  was adamant that he wanted the exact one he had ordered as that was what Diana herself had picked. It was a ploy  on the part of Repossi to make a real killing on the sale, his excuse to that effect being that Diana deserved a ring tha was well worthy of her social pedigree.  With Dodi having expressed disaffection, Repossi rendered his apologies and assured Dodi he would make the right ring available shortly, whereupon Dodi repaired back to the hotel to await its delivery. But Dodi  did insist nonetheless that the pricier ring be delivered too in case it appealed to Diana anyway.

Repossi delivered the two rings an hour later. They were collected by Roulet. On inspecting them, Dodi chose the very one he had seen in Monte Carlo, apparently at the insistence of Diana.  There is a possibility that Diana, who was very much aware of her public image and was not comfortable with ostentatious displays of wealth, may have deliberately shown an interest in a less expensive engagement ring. It  may have been a purely romantic as opposed to a prestigious  choice for her.

The value of the ring, which was found on a wardrobe shelf in Dodi’s apartment after the crash,  has been estimated to be between $20,000 and $250,000 as Repossi has always refused to be drawn into revealing how much Dodi paid for it. The sum, which enjoyed a 25 percent discount, was in truth paid for not by Dodi himself but by his father as was the usual practice.

Dodi was also shown Repossi’s sketches for a bracelet, a watch, and earrings which he proposed to create if Diana approved of them.

DIANA AND DODI GUSH OVER IMMINENT NUPTIALS

At about 7 pm,  Dodi and Diana left the Ritz and headed for Dodi’s apartment at a place known as the Arc de Trompe. They went there to properly tog themselves out for the scheduled evening dinner. They spent two hours at the luxurious apartment. As usual, the ubiquitous paparazzi were patiently waiting for them there.

As they lingered in the apartment, Dodi beckoned over to his butler Rene Delorm  and showed him  the engagement ring. “Dodi came into my kitchen,” Delorm relates. “He looked into the hallway to check that Diana couldn’t hear and reached into his pocket and pulled out the box … He said, ‘Rene, I’m going to propose to the princess tonight. Make sure that we have champagne on ice when we come back from dinner’.” Rene described the ring as “a spectacular diamond encrusted ring, a massive emerald surrounded by a cluster of diamonds, set on a yellow and white gold band sitting in a small light-grey velvet box”.

Just before 9 pm, Dodi called the brother of his step-father, Hassan Yassen, who also was staying at the Ritz  that night, and told him that he hoped to get married to Diana by the end of the year.

Later that same evening, both Dodi and Diana would talk to Mohamed Al Fayed, Dodi’s dad, and make known to him their pre-nuptial intentions. “They called me and said we’re coming back  (to London) on Sunday (August 31) and on Monday (September 1) they are

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Columns

RAMADAN – The Blessed Month of Fasting

28th March 2023

Ramadan is the fasting month for Muslims, where over one billion Muslims throughout the world fast from dawn to sunset, and pray additional prayers at night. It is a time for inner reflection, devotion to Allah, and self-control. It is the ninth month in the Islamic calendar. As you read this Muslims the world over have already begun fasting as the month of Ramadan has commenced (depending on the sighting of the new moon).

‘The month of Ramadan is that in which the Qur’an was revealed as guidance for people, in it are clear signs of guidance and Criterion, therefore whoever of you who witnesses this month, it is obligatory on him to fast it. But whoever is ill or traveling let him fast the same number of other days, God desires ease for you and not hardship, and He desires that you complete the ordained period and glorify God for His guidance to you, that you may be grateful”. Holy Qur’an  (2 : 185)

Fasting during Ramadan is one of the five pillars upon which the structure of Islam is built. The other four are: the declaration of one’s belief in Allah’s oneness and in the message of Muhammad (PBUH); regular attendance to prayer; payment of zakaat (obligatory charity); and the pilgrimage to Mecca.

As explained in an earlier article, fasting includes total abstinence from eating, drinking, smoking, refraining from obscenity, avoiding getting into arguments and including abstaining from marital relations, from sunrise to sunset. While fasting may appear to some as difficult Muslims see it as an opportunity to get closer to their Lord, a chance to develop spiritually and at the same time the act of fasting builds character, discipline and self-restraint.

Just as our cars require servicing at regular intervals, so do Muslims consider Ramadan as a month in which the body and spirit undergoes as it were a ‘full service’. This ‘service’ includes heightened spiritual awareness both the mental and physical aspects and also the body undergoing a process of detoxification and some of the organs get to ‘rest’ through fasting.

Because of the intensive devotional activity fasting, Ramadan has a particularly high importance, derived from its very personal nature as an act of worship but there is nothing to stop anyone from privately violating Allah’s commandment of fasting if one chooses to do so by claiming to be fasting yet eating on the sly. This means that although fasting is obligatory, its observance is purely voluntary. If a person claims to be a Muslim, he is expected to fast in Ramadan.

 

The reward Allah gives for proper fasting is very generous. Prophet Muhammad (PBUH) quotes Allah as saying: “All actions done by a human being are his own except fasting, which belongs to Me and I will reward it accordingly.” We are also told by the Prophet Muhammad (PBUH) that the reward for proper fasting is admittance into heaven.

Fasting earns great reward when it is done in a ‘proper’ manner. This is because every Muslim is required to make his worship perfect. For example perfection of fasting can be achieved through restraint of one’s feelings and emotions. Prophet Muhammad (PBUH) said that when fasting, a person should not allow himself to be drawn into a quarrel or a slanging match. He teaches us: “On a day of fasting, let no one of you indulge in any obscenity, or enter into a slanging match. Should someone abuse or fight him, let him respond by saying: ‘I am fasting!’”

This high standard of self-restraint fits in well with fasting, which is considered as an act of self-discipline. Islam requires us to couple patience with voluntary abstention from indulgence in our physical desires. The purpose of fasting helps man to attain a high degree of sublimity, discipline and self-restraint. In other words, this standard CAN BE achieved by every Muslim who knows the purpose of fasting and strives to fulfill it.

Fasting has another special aspect. It makes all people share in the feelings of hunger and thirst. In normal circumstances, people with decent income may go from one year’s end to another without experiencing the pangs of hunger which a poor person may feel every day of his life. Such an experience helps to draw the rich one’s conscience nearer to needs of the poor. A Muslim is encouraged to be more charitable and learns to give generously for a good cause.

Fasting also has a universal or communal aspect to it. As Muslims throughout the world share in this blessed act of worship, their sense of unity is enhanced by the fact that every Muslim individual joins willingly in the fulfillment of this divine commandment. This is a unity of action and purpose, since they all fast in order to be better human beings. As a person restrains himself from the things he desires most, in the hope that he will earn Allah’s pleasure, self-discipline and sacrifice become part of his nature.

The month of Ramadan can aptly be described as a “season of worship.” Fasting is the main aspect of worship in this month, because people are more attentive to their prayers, read the Qur’an more frequently and also strive to improve on their inner and outer character. Thus, their devotion is more complete and they feel much happier in Ramadan because they feel themselves to be closer to their Creator.

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