All clinicians work in an environment that is resource-constrained in some way. However, recent press coverage has alluded to deteriorating conditions in state health establishments to such an extent that clinicians are concerned about the well-being of patients, writes Dr Graham Howarth, head of Medical Services – Africa at Medical Protection Society.
Dr Howarth writes:
Requests for assistance to the Medical Protection Society also suggest that there are increasing concerns regarding patient care in government facilities and members are seeking advice on what can be done.
As an employed doctor you have obligations not only to your patients but also your employer. Working in such a resource-constrained environment may be tremendously difficult. You may be extremely concerned, indeed irritated, and under some circumstances this may also affect your personal well-being. However, while it’s easier to say than do, perhaps the first rule is to try to be as dispassionate as possible.
Try not to become emotionally involved and, if emotional involvement is inevitable, ensure you are able to manage these emotions and not allow them to affect your clinical judgment.
Of course this is not to say that clinicians should be uncaring about how their patients are affected by the conditions in which they are placed. Rather, expressions of anger will not improve the level of care you can provide to your patients and are more likely to get you into trouble. It is also not inconceivable that the person at whom you direct your anger is equally disturbed and wishes to assist but faces the very same constraints.
Once you are able to manage your frustration or anger, what is the way forward? The assessment of a healthcare professional’s conduct is objective and one would be judged against what would be expected of the reasonable healthcare worker under similar circumstances.
First, are things as bad as you think they are? Are colleagues concerned and have they articulated these concerns? These conversations have to be cautious, reasonable and measured, as you do not wish to be accused by your employer of promoting dissent. Also, ask yourself and your colleagues: are there ways of solving the problems at hand?
Given one’s obligation to patients, if you and your colleagues have valid concerns then it would be prudent, in the first instance, to raise them with your line manager, preferably in writing. If you decide to escalate correspondence beyond the line manager then you need to ensure the line manager has had a reasonable opportunity to respond and the response is such that you have reached an unacceptable impasse. Alternatively, you could escalate if the line manager has not responded at all.
When raising an issue in writing with a line manager, again, do so in a dispassionate way, pointing out your concerns and perhaps adding that they are not your concerns alone but that they are shared by colleagues – if that is indeed the case. If you feel that you have reasonable solutions then now would also be a good time to raise them.
In writing to your line manager it may well be worthwhile pointing out that, were a patient to be harmed and subsequently sue the hospital, then the hospital retains liability not only for the resource problems but also for the conduct of its employees.
You may wish to point out that if your care is criticised and a patient complains to the Health Professions Council of South Africa, doubtless the role of resource constraints could play a role in your defence. There is a tendency in this sort of correspondence to copy in all and sundry. Be mindful of who is copied into such correspondence.
Despite your concerns about resources you would be well-advised to do your best under the circumstances. Refusing to work is likely to create tensions between you and your employer and this may lead to disciplinary action. While you should not subject patients to undue risk of harm, this has to be balanced against your and the State’s obligation to render care.
Given the potential for conflict it is advisable to involve and seek assistance from your indemnifier and your union. The indemnifier can assist in clearly setting out your obligations to patients and issues of patient safety, while the union can assist in issues of employment law and the possibility of disciplinary action being taken.
We appreciate it is extremely difficult for healthcare workers working in resource-constrained circumstances where they have very real concerns about patient safety and well-being. Members often feel that they joined the profession to help people and perhaps remain in the state sector to try to ensure that as many patients as possible receive optimum care, and they feel they are letting down their patients.
This can lead to frustration, anger and even illness. While frustration and anger may be understandable, do not let it boil over into personally trying to resolve the issue. It is unlikely to be successful and may cause problems for the practitioner who strikes out.
Whistle-blowing, going to the press, or industrial action should be extremely carefully considered. While such action may appear satisfying in the short term – and there is understandably a high level of support for recent whistleblowers – there are potential consequences for the individuals involved, and this course of action should preferably not be taken in the absence of professional advice.
Regrettably, healthcare professionals working in some state hospitals may continue to face poor, resource-constrained conditions. If you are in any doubt about how these conditions may affect the safety of your patients, and subsequently your medico-legal risk, you are advised to contact your indemnifier for advice.
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