Nothing but the truth

I’ve often come into situations where my patient is asking me something about themselves, their condition or their lifestyle. And I often never know how to answer them. More specifically, when it comes to weight, I never know how or if I should say that they are feeling their level of discomfort due to their enormous bellies.
So how do we have that conversation with our patients?
One of my clinicians was telling me about several situations where patients would come to her begging for pain relief for their lower back aches, when they were too in fact big to shuffle more than ten steps at one time. Her being the type of person she is, wasn’t too shy to tell these obese people the truth, and told them to lose drastic amounts of weight before they consider coming back to physiotherapy again. In another case, she told a woman who had lost her leg to diabetes that she would never qualify for prosthesis because she was grossly overweight.
In my experience, I had a patient who was morbidly obese, and complained of lower back pain. I struggled so much to actually palpate her spinal cord, and distinguish between her different spinous process levels. My clinician at the time said to me that I was wasting my time on this woman, and that I should refer her on to the dietician, give her home exercises and advice, and send her on the way. If she loses weight and continues to feel this pain, she may return for further investigation.
These situations continued to haunt me. I was torn between the frustration of “oh my goodness, look in the mirror and recognize your problem” and “these poor people just keep getting pushed around the medical team because no one wants to tell them the truth.” Like in one situation, I had a woman who had her leg amputated above the knee, because she tripped over a lifted carpet, landed on her knee and severed her popliteal artery. By the time this woman noticed something was wrong, her leg from her knee down was dead. Now I come in post op, to begin therapy, and attempt mobilization with a walking frame, and this 150kg woman can barely stand up on two legs let alone one. At this point in time, I am so frustrated with her because she just wants a wheelchair to go home with and won’t even attempt to shuffle to the bedside chair. I so badly want to scream out that there are patients with multiple amputations who are attempting to walk (who actually really need a wheelchair); while she can actually change her weight, she refuses to do anything. Eventually, we manage to walk out into the passage with the walking frame, and back to bed and she gets discharged. But then 8 weeks down the line I bump into her at a rehabilitation centre; in a flipping wheelchair!! And that’s when I actually want to lose my cool (my professional physiotherapist cool). And the only thing that’s limiting her mobility is her weight?!
Also at mini back classes and exercise class that some CHC’s give for chronic mechanical back pain, I’ve encountered similar cases. Most of the people that attend these classes have pretty high BMI’s, and still struggle to understand why they have this chronic back pain. I struggle so much to stop the words “because you’re fat” pass my lips. But then I also struggle to explain to them in a professional way, that they are overweight and that losing weight will help their discomfort. Why; you ask? – Because I’m so worried about their reaction. Most people are oblivious or perhaps even naive about their weight, that they can’t see why their weight would affect their health.
My ethical dilemma here has two points. Is it ethical to refer patients on, just because they are obese and won’t benefit immediately from physio without weight-loss? And how do you ethically let someone know about their generous spread of weight?
Firstly, I feel it is unethical of the doctor to refer obese patients to us to help with weight-loss. Because that’s an incorrect referral. The doctor should first refer to the dietetics department for the patient’s lifestyle to be assessed. Also, the doctor should explain that weight-loss would greatly benefit the patient prior to seeing the physio. In this case, physiotherapy should be seen as a last resort for assistance. However, if the patient is referred to us, we can’t take it out on the patient that the referral was incorrect. We should make an attempt to “council” the patient, work out an exercise plan, and meet with the patient monthly to follow the weight-loss progress. Writing the patient off right away is unethical in itself, as it is practically refusing to treat the patient just because of what they look like. But on the other end of the stick, I feel that seeing this patient once a week, just to put IF on for 15 minutes and a massage is not beneficial to us nor the patient. And we could’ve treated someone with greater priority in those wasted sessions. According to mirco-allocation (balancing patients’ needs); one needs to decide what patient gets priority over another patient. If we chose the six material principles of justice, we should prioritize patients according to their need, their effort, and their contribution and ensure everyone has equal opportunity. Therefore, by giving such a patient the opportunity to treatment, they need to show the above mentioned traits to keep a high priority with regards to treatment allocation.
Then to answer the second dilemma, I feel that the ethical guideline of disclosing information about their condition to a patient should apply in this case as well. The patient’s condition is obesity; therefore if no one has yet explained this condition to the patient, then it is our duty to do so. According to Professional ethics in physiotherapy (PT402) module, when helping patients deal with terminal illness, one should not destroy their hopes but convey a message that things could improve, however always be honest and truthful. And this guideline applies to me when helping a patient deal with any condition. In the same case, we wouldn’t lie to a terminally ill cancer patient that everything is fine and they can walk their daughter down the aisle in 8 months time. So we can’t lie to our patient who is obese and say; “no ways, you look fantastic, weight-loss is not necessary”.
So in future practice of my own, I need to suck up my embarrassment and awkwardness and discuss my patient’s condition with them, professionally and ethically – whether it be about obesity, sexual dysfunction or terminal conditions. Also, I will strive to put my patient first, refer them to the correct health professionals, and assist them in any way that I can, without “wasting” my time with unbeneficial treatments.

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Torture Diagnosis – But it’s cheaper

Recently a friend of mine was admitted into to hospital for constant painful stomach cramps. Several tests were run, blood was sent away, an ultrasound and x-ray was done yet still nothing conclusive was found. The doctor finally ruled the basic gastro as the source of the problem. Now because she doesn’t have medical aid, all of this came to her own personal expense. She said she had to swipe her card for every extra test they wanted to run, because just in case it is something serious, then they may miss it if she doesn’t get the test done.
Now she is at home and recovering with mild medication – at a great cost; and awaiting several bills for her 12 hour stay in hospital, her doctor’s consultation, and her blood work results.
Now this reminded me of a time when my boyfriend had injured his hamstring and he was having constant pain around the medial aspect of his knee, several weeks post injury. I started to query possible avulsion fracture or hairline fracture at the site of the hamstrings insertion. Yet he didn’t want to pay so much money to have and x-ray or an MRI if I wasn’t a hundred percent sure it could be a fracture. I consulted my clinician at the time at a CHC where I was working. She said it could be an avulsion fracture or a grade one or two tear of the hamstring close to the insertion of the hamstrings. But she said if he really wanted to be certain, he should speak to a specialist who could diagnose it for him. She then continued to say, if he really wants to be sure, I could bring him in, and she would do ultrasound over the painful area.
Now my knowledge tells me that fractures or possible fracture sites are a contra-indication for the usage of ultrasound. Yet she explained that if she goes over the area of concern, and he screams out in agony; then it is definitely a fracture; and won’t need to feel like he is wasting his time and money to go for a scan. Obviously the ultrasound will cause an osteophyseal burn at the fracture site and this is why it will increase his pain – and why it is contraindicated. However; it is a sure way of diagnosing a fracture in half the time and costs.
This now gave me my basis for my argument over the use of such a cruel way of diagnosis.
One side of me says this is torture? How can you inflict pain on someone without their consent in order to diagnose them and perhaps cause more harm? And then also be okay with it? It sort of reminds me of women going for facial waxes or Botox just to look more appealing but it’s so painful. As the beautician, I would feel so guilty doing all these painful things on other people. But then again, it’s what the client wants and it doesn’t (or shouldn’t) cause any permanent or bodily harm.
The only “justification” (if that’s what you can call it) I can give this, is that it is quick and cheap. In public health services, the patient gets an appointment with the doctor roughly two weeks after the “non-serious” sports injury. They then get referred to a physio at the local clinic and get an appointment for two weeks later. Now at four weeks post injury, they see the physio – who then suspects a possible fracture and then refers the patient back to the doctor in hopes that he will refer the patient on to x rays. Now 6 weeks post injury, the patient has had x-rays, and the newly qualified technician struggles to see a hairline fracture on the low quality x-ray and writes a report to the doctor, who yet again refers back to the physio. So, you as a physio find some indication to apply ultrasound on the patient, and boom, he screams in agony because you have unknowingly caused a burn.
Unfortunately the use of an ultrasound to diagnose immediately is justified better in the public health system due to time delays and a heavy back up in patient load. Had this patient been “diagnosed” by the physio with the ultrasound at the first physiotherapy appointment; he would’ve greatly reduced his travelling costs and time spent going back and forth. There is another dilemma in this case, for the clinician to provide a reasonable level of care when there are limitations due to inequitable distribution of resources. There are guidelines that should be followed to work through this dilemma;
• Seek tests or treatments that will accomplish the diagnostic or therapeutic goal for the least cost,
• Minimize the use of marginally beneficial tests or marginally beneficial interventions,
• Advocate for one’s own patients but avoid manipulating the system to gain unfair advantage to them (Martin et al, 1997)
But then again, had the health system in South Africa been a dream and been prompt and professional, this whole saga would’ve been cleared up in a matter of days and no one would’ve been burnt or sued.
But what if you say to the patient, “Listen, I think you have fracture, but it’s going to take a couple of months for you to actually have an x-ray done. So I can use this machine to find out and if it’s positive it will cause extreme brief pain. But the diagnoses will be immediate. Which would you prefer?” and what if they said okay, let’s take the short cut. Then the patient has given you permission to perform a painful test on him to quicken the process. Then is this unethical and inhumane thing that you’re doing, no longer inhumane or unethical?
Okay, we now may be pushing the boundaries into the argument of euthanasia. Because if your patient can ask this of you and it’s acceptable for you; then what is too much of your patient to ask for. But that’s a whole another can of worms.
If I speak from my moral and ethical approach; it upsets me that my patient has too spend eight weeks and monthly wages finding out what is wrong with him when the answer is standing behind a door of brief pain. But then again, as a health professional, I wouldn’t be able to inflict pain on another just to take the easy short cut. I suppose I’m stuck in a catch 22, which forces me to look to our health system to be more patient centered.
Also, what sort of unethical monster are you for offering that sort of option to a patient. Because if you offer it to a big strong man with a high pain threshold, then a mother with a four year old girl, and a very low threshold also wants the same short cut. And, if you can offer such a short cut, how far down the line are you from offering a lethal dose of morphine to a suffering terminal cancer patient?
Thus, we can only look to our health system for answers, and assistance in speeding up diagnostic process and make them more affordable. Because it’s practically unethical for our own health system to force their practicing professionals to even ponder over the fact of providing speedy, efficient yet inhumane and torturous diagnostic tools.

Martin F. McKneally, Bernard M. Dickens, Eric M. Meslin, Peter A. Singer (1997). Bioethics for clinicians: 13. Resource allocation. Canadian Medical Association Journal, 157 (2): 163

Are we really protected?

This little rant of mine comes at a time when I’m thinking about my future and my career as a physiotherapist. I’m thinking about one day cutting the metaphorical red bow to open the doors of my very own practise. I’m thinking about going on to do my masters and perhaps PhD, and becoming the world’s greatest physiotherapist. Then I’m thinking about that practical exam where we had to give a “patient” a heat pack for painful lower back. I’m thinking about our most feared lecturer scrutinised our every move and failed us if even a micro-fraction of the heat pack was peeking out of the towel – claiming that if this were a “real” patient, we could be sued and perhaps be suspended by the HPCSA. I’m now nervously thinking how quickly our licence to practise can easily be stripped with a minute sliver of a burn on a patient who is having a bad day and decides to sue.
This got me thinking, how quickly does the HPCSA intervene? And how do they even know what I am doing if no one speaks up?
Now comes the small rant. I came across an episode of Carte Blanche (http://carteblanche.dstv.com/hpcsa-doctors/) the other day and they were investigating a case of malpractice against a plastic surgeon in Benoni. This guy was being sued by several patients who complained of disfigurement including lower limb amputations and irreversible scaring. In the many cases, he had done “simple” procedures that a trained veteran surgeon could complete in his sleep, yet many patients came out unhappy. Let’s rephrase that. Not unhappy like ungratefully disappointed that their tummy-tuck hadn’t given them a six pack. But rather unhappy that their elective breast reduction had resulted in lumpy, scared, nipples breasts.
But this isn’t even the good part yet. As a soon to be registered health professional, I’m not really bothered if this guy botched all his surgeries and got away with it. However, as someone on the other end of the stick, and as a patient to many registered health professionals – this is where I get worried.
What bothered me, was the fact that after attorneys brought this doctor to the attention of the HPCSA in September 2013, nothing was done to suspend this doctor during investigation (http://www.enca.com/south-africa/hpcsa-sued-over-plastic-surgeon.) Therefore he continued to practise, and continued to cause more emotional, financial and physical damage to several patients up until February the following year. This forced the attorney representing the angry patients, to lay a case against the HPCSA – pleading the high court to force the HPCSA to suspend this surgeon.
Now how unethical can this be? Surely it’s so unethical that it’s illegal.
The HPCSA claims that they are a “statutory body, established in terms of the Health Professions Act and is committed to protecting the public and guiding the professions.” Committed to protecting the public? Yet in this case 10-30 patients of this doctor are left scared for life because the HPCSA failed to act promptly.
On the HPCSA site the state the following;
“To protect the public, we:
•set standards for registrants’ education and training, professional skills, conduct, performance and ethics;
•keep a register of professionals who meet those standards;
•approve programmes which professionals must complete to register with us; and
•take action when professionals on our Register do not meet our standards.
This means that professionals registered with us are sincere and meet national standards. This offers you protection if professionals fail to meet these standards. You can also check with us that a professional is registered.”
(http://www.hpcsa.co.za/About)
The settle the public by saying they will take action on those professionals who don’t meet their standards. But what are these standards? Surely they don’t include botching simple surgeries. And if the standards are not met, what action will be taken? Again, this is not mentioned. Also, they don’t give piece of mind to the public that immediate and/or severe action will be taken on those of malpractice.
As a regular citizen, I feel cheated by the HPCSA I feel as though they are as slow and backwards in protecting us, as our current policing system. As a health professional, I feel guilty that the public is not protected. I am worried that because of the HPCSA’s snail pace reactions, all health professionals could be painted with the same brush as this surgeon or previous unethical surgeons. The public may view us all that we aren’t really committed to doing “the right thing” because the fear of getting caught is no longer there.
Now I’m not saying this is how I will practise, just because now I don’t have someone fully aware watching over my shoulder. Because then I am being just as unethical as the HPCSA.
One of my previous clinicians, who could possibly be the most ethical clinician I have come across, said to me, treat every patient as you would want to be treated – which is pretty much a given. But he also always said something to us which was, “you may know of those kind of physio’s that you wouldn’t dare send your mother or your worst enemy to – don’t be that kind of physio.”
So just for some confirmation, in the light of what I have just discussed, I feel this won’t affect how I continue to practise, as I wouldn’t want to send my worst enemy to a slacking physio, so I’m not going to be that physio.
That’s it, rant over. 

Little white lies

This post is more about something I’ve done once or twice thinking I was doing the right thing when instead, I was not.

I recently filled out a referral form for a patient who was applying for placement at a pretty decent rehabilitation placement. As the questions came along, I ticked the appropriate boxes.

  1. How does your patient mobilize – with some supervision I ticked.
  2. How does your patient transfer – independently I ticked.
  3. What is your patient’s motivation – excellent I ticked.

And so it went on. But you see; this isn’t really how my patient presented at the time of completing the form. She couldn’t stand up on her own with the walking frame and therefore couldn’t even take a step with the walking frame. May I add, she was also poorly motivated and would much rather lie in bed and read magazines than attempt to move around independently.

Therefore in essence I lied about her initial assessment. This is totally unacceptable according to “Forensic Document Examiner”.

Referral forms are just as important and legally bound as what daily doctor’s notes are, so what made me think I could just bump my patient up in her restrictions? According the HPSCA, the disability assessment forms constitute as patient records and hold the same value as patient records.

Well, in all honesty, I do feel like deep inside my heart I was trying to do the best thing for my patient. And that was to improve her chances of getting into a decent rehabilitation clinic, which would better her outcome at the end of the day. I know through experience in my previous year of work, that some rehab clinics only accept the most independent and functional patients, who are most likely to improve with rehab and have great motivation. Therefore, if they receive a referral for a patient who has poor motivation and is highly dependent on nursing stuff, they are less likely to accept the patient at hand.

Therefore, in my patient’s best interests, I told a few white lies with the intention of improving her chances to be accepted by the rehab clinic.

So was this not the best thing I could do for my patient? I mean I had every intention to attempt to bring her to the functional level I had boasted about in the form, while the form was being sent out. This hopefully would mean my patient would be at the level at discharge that I had described two weeks earlier.

This unfortunately to my dismay is pretty much unethical and fraudulent. Firstly, lying about a patient’s condition, whether it’s improving the fact or worsening the fact is wrong. Because that patient is going to arrive at the clinic with the expected functional level and be completely way off – thus wasting time and effort of the rehab staff. And because, lying is lying, whichever way you put it. And the HPCSA states in its code of conduct, that truthfulness is imperative to good practice.

Also what I have essentially done is decreased the chances of someone else being accepted because their functional level and predicted outcome is not as successful as my patients make believe functional level and outcome. Therefore, by being too invested in my patient and centering all my attention on my patient, I have denied decent therapy to many other patients.

Which is wrong – no matter how it’s put?

Therefore the next time a referral letter comes my way, I just have to bite the bullet and tell it like it is. I have to try my best to get my patient to the highest functional level at that point and record that in my referral form. This is the only way I can remain fair and truthful to my patient and the several other candidates. By doing this I also refrain from deciding who deserves rehabilitation and who doesn’t. Because at the end of the day, where is the line drawn? Yesterday I may have lied in my notes and said my patient’s secretions were cleared by the end of the session because that makes me an effective physio. When in actual fact, after all my manual techniques, I still couldn’t effectively clear his secretions. Then today, I may lie about my patient’s level of disability so that they may be accepted to a rehab center to benefit from further treatment. And then tomorrow, I lie about my patient’s disability so that they may receive some sort of funding based on their disability level.

 So where does this stop?

When do I say; “Okay, I think I have lied enough now, this patient must actually help himself.”

It’s very easy to get carried away and caught up in the moment, trying to help your patient. But I can’t lie for everyone, nor can I lie for some. Therefore, I can only tell the truth, and leave the responsibility of partaking in rehab in my patients hands.

Unfortunately, our government or our health system can cope with ‘freebies’. And who am I, a measly fourth year undergraduate student with minimal clinical experience, to determine who gets “better” rehabilitation and who doesn’t? Again, this is something I cannot do, and the only way around this issue, is honesty and equality. Every patient deserves the same level of medical attention as the next, therefore I cannot create mini competitions to see who deserves it more.

I don’t wana see you today

Recently I had a chat with a friend of mine who is also working at the same hospital as me but in another ward. We were discussing the “prisoner patient” in her ward which is need of her physiotherapy attention and treatment. Us being silly girls were fretting over how dangerous he could be, and how woman hungry he must be since being in jail and all. And now he needing physio attention from a girl was just the icing on the cake!

So after she reluctantly saw him, we begged her to tell us how the session was. And to my surprise she said he is actually a really nice guy and pretty kind hearted. He thanked her numerous times for her help and cooperated well during their time together. We were both pretty dumb founded about how nice he turned to be and how judgemental we were before she even met him.

This got me thinking about different instances when my peers or I really didn’t want to see patients because of one or other excuse.

For example, another peer of mine really didn’t enjoy treating a specific patient and often made her sessions with him very quick, if it was really necessary that she had to see him – but when is it not really necessary to see a patient? Needless to say, he had a very bad chest, secretion retention that required multiple suctioning per day and he was disoriented and confused. The latter probably scared my peer off. Anyways, when returning to hospital after the weekend, we found put that this patient had passed away.

Now, some part of me is saying this happened because she skipped the Thursday session with the patient and also didn’t treat him effectively due to not wanting to be with him for very long. Please know, that I am not blaming her for his death, I’m just saying, her poor treatment techniques or lack thereof may have contributed to his passing. So she may have indirectly assisted with his death. The doctor’s final report was that this patient died of secondary respiratory complications – which I believe was totally preventable, if chest physiotherapy was adequately given. This situation angered me as I helped her with this patient at one point and grew to empathize with him. So it was understandable to feel sad in his passing. Suspended treatments are not a rare occurence when it comes to the health system in South Africa. Some patients are being turned away due to lack of supplies, equipment, staff or general space in the hospitals.

Again, please don’t see this as a post where I am keeping my conscience clear and believing that I am all righteous, because this has happened to me numerous times – although I just don’t know of any devastating effects such as death happening in my wake. Believe in me, I have had those days where I have done a little happy dance in my head, where the patient who stinks, or the one who is confused or stubborn, has been discharged, transferred or sent for surgery on the day of treatment. There have been times where I have had to physically and mentally prepare myself and give myself a mini pep-talk prior to starting with those “difficult” patients.

While we here, my lecturer said something that has always stuck with me;

“You never get difficult patient’s, you just get poor physiotherapists” – Dr. M. Rowe.

Anyways, the point I am trying to make is that, even if you think a patient is stupid, stinky, dirty or just plain irritating; they’re still a human being who is requiring medical attention and it’s their human right to receive the best medical attention at their disposal.

This “ethical” dilemma that I have stumbled across has actually left me a lot to think about when it comes to my own clinical practise as well as my effectiveness as a physiotherapist.

This blog post has taken me the better part of a week to write, and while writing I have thought about ethics and patient rights while treating my patients. The Patient Rights Charter says it is the patients right to receive proper medical attention and is not allowed to be refused from treatment.

Only the patient can make the final call about whether he wants treatment or not, and whether he is going to have an operation or not. Otherwise, it is the medical professionals’ responsibility to give that patient the best medical attention they can possibly give. The patient also has the right to continuity of care, which means that no one shall be abandoned by a health care professional worker or a health facility which initially took responsibility for one’s health. This means that I cannot suspend treatment just because the patient does not meet my standards of appropriateness that is not medically related.

Therefore, I have agreed, by choosing to study a health profession, that I have several responsibilities to uphold to protect and help my patients. My patients, also, don’t know what is wrong with them and don’t know what they deserve or what their rights are. Therefore their lack of knowledge makes them vulnerable and this is what medical professionals use to take advantage of patients. Therefore, by not seeing my patient daily, I have in theory, told them that they do not deserve therapy. Which once again; is threatening their basic human rights.

I must say confess, that in the beginning when I first began with clinical practise and blocks, I felt too guilty to not see a patient. So, to give my conscience some peace of mind, I saw my “difficult” patients, but only for a short while. As time and experience went one, I became more frustrated with these “difficult” patients and began to find several excuses not to see these patients. Now, in retrospect, I can see how easily it was to get carried away and make myself believe that I wasn’t doing anything wrong. But then, once in a while, I’d get a really “nice” cooperative patient with great potential. I’d work really hard with this patient and see massive improvement and then be filled with an amazing high because I was effective! Then I’d think, if only I worked this hard with each patient, then perhaps they would progress the same and I’d experience a high with each patient.

However this isn’t so easy or simple.

Patients who possess traits that are not favourable to me, or have stubborn and unmotivated personalities are the patients who test my quality and effectiveness as a physiotherapist. These are the patients I actually need to work the hardest on. These are the patients I need to hold my tongue with and take a deep breath, and push through it.

Violating the Vulnerable

A couple of weeks ago, I was speaking to my boy-friends mother about her constant knee pain and what her orthopedic doctor had decided to do about it. She said that she needs to have an operation on the knee as well has have her heel spurs shaved down. However she was feeling uneasy about having surgery done as she doesn’t like knowing that she is going to be laying on a table knocked out and vulnerable to everyone in the room. At first I was very surprised as I was thinking, but why? The surgery is going to help you at the end of the day. But that’s just me, wither being very naïve to the world out there or just having complete trust in our health system whereby the guy is there to operate on you and that’s it. No funny business.

But what if there are those strange encounters? Or weird doctors who are up to no good?  – And slaved almost a couple decades of their lives just to get a little “freaky” with an unconscious person in a room supposedly full of other highly qualified medical “professionals”.

Now I say “professionals” like that, because if these people are getting up to weird or wonderful things, what makes them professional? But that’s going off on another tangent.

To get back to the original topic, I did some research and found that recently a anesthesiologist in Toronto was sentenced 10 years in prison for sexually assaulting 21 (twenty one!!!!) sedated women during their surgeries.

(www.m.theglobemail.com/news/toronto/doctor-who-assaulted-patients-during-surgeries-sentenced-to-10-years/article17079114/?service=mobile).

The serving judge, David McCombs describes the doctor’s violations as leaving his victims with deep feelings of betrayal – that these offences were committed during surgery, by a medical doctor, in a operating room, a place of ultimate vulnerability and trust.

I bet you’re wondering; how did he get away with this with a room full of medical staff? Well, the Canadian press reports; that he was known as a “touchy-feely” doctor and was often seen stroking his patient’s cheek or hair in a soothing manner during surgery. Therefore alarm bells didn’t start ringing when his physical proximity was noticed even while he sexually assaulted the women while concealed by only a surgical drape.

Then you ask; how do these women know that they’ve been assaulted? Well it was reported that the patients received indecent whispers in their recovery room, as the doctor described to them everything he had done to them while they were out. Seriously? Was he asking to be found guilty!?

In another story, published on FoxNews.com in 2011, anesthetized patients in Australia were being subjected to genital, anal and breast examinations by medical students. The operating surgeon wound have his group of students practice their physical examination on the unconscious patients.

(www.m.naturalnews.com/news/031155_medical_students_anesthesia.htm).

It continues by explaining that 82% of medical students are often pressured into sodomizing their unconscious patients just because their medical instructor enforced their authority and told them to do so.

Now this isn’t the only type of violation in the operating room.

There have also been reports of patients inappropriately exposed, whereby the nursing staff has not decently covered their patients. By law you are supposed to be fully covered with sterile cloths and the necessary operating area needs to be exposed (reference). However this is not happening. Somehow (the big guy up there only knows), patients are being informed of how indecently they were exposed during surgery.  

Now all this talking about horror stories in the OR has got me thinking about my own experiences, but it’s not half as scary, yet just something to think about. Being on a clinical block at one of the government hospitals in Cape Town, I was invited along with a friend to tag along with the surgeon in his surgery. This was all very exciting to me because some small part of me wishes I pushed myself into medicine rather than physiotherapy (but that’s a story for another day).

Before the actual cutting started the patient lay there, knocked out on her tummy with her head at a slight decline forcing the rear end to push up into the air like something you’d see in a yoga class. This inevitably left her “rear end” in a position I think not even her husband has seen.

Fortunately she wasn’t left like this and her body was covered appropriately, leaving only the small of her back exposed for the operation. But the damage was done and I had seen a little more I had hoped for, while everyone carried on like it was a common thing. – Perhaps that was just my immaturity and inexperience that was shining through in those early moments? Anyways, the surgery continued and it was successful with no side order of funny business. But afterwards I was left with a thought of, did this women give her consent to have two students, who know nothing about surgery, peering into a hole in her back.

Now most people would say for something like this, consent isn’t really necessary, well it’s not much different than having surgery over her chest with her boobs exposed. And that is something I’m sure you would not give consent for to have random people staring into your chest. Because what happened to doctor-patient confidentiality? So surely this woman should give consent to have us in there? Is it not the same thing as having clients give consent to have students sits in during out-patient physio sessions? If I were that woman, I’d feel uneasy knowing other people were there just to have a look. However if it were more of an invasive surgery over or near a private area of mine, I would feel violated to have people just gaining an experience rather than actually doing something of value.

So what does the South African law say about all this?

Are we as patients protected of anything were to happen?

And or we as medical professionals supposed to follow some sort of code of conduct that stops us from doing something stupid.

The HPCSA describes that the patient has the right to confidentiality and privacy as well as informed consent (point 2.7 & 2.8). This means patient treatment cannot be disclosed without consent and treatment and procedures cannot be done without consent (Constitution of the Republic of South Africa (Act No 108 of 1996) – Patient Rights Charter).

So what does this mean for me? Well, in the future I will remember about everything I have researched here and described here, and this will help me to protect my patients from any sort of violations. I need to remember what it would be like if I were the patient and wonder if I would like to have my whole chest exposed while being auscultated. The simple answer is no, so then this is something I need to take into account every time I undress my patient or open up their sheets and take a peek at their injuries.

don’t look back, you not going that way…

This last post for the year has got everyone looking back and going through what they’ve done. However, I’m not looking back, I’m taking what I’ve learnt to look forward and carry me through future experiences. As Mike said in the beginning, we will learn without even knowing it and that is something I am only now sure of.

One of the things I have taken away with me after the past few weeks is that everyone has different opinions and ideas and that’s something we have to experience. It has been very frustrating for me in the past to argue with people with contradicting ideas. Being a very stubborn person I have always had the “my way or highway” mindset whether it comes to debating ethical topics, choosing movies or takeout choices. This often leads me into trouble because no one wants to be around a bossy boots as well as the fact that you get nowhere without an open mind. It’s definitely important that everyone has different ideas, opinions or beliefs otherwise we would live in a rather boring world where everyone went along to the same things. I suppose it would have its positives if everyone had one mind set as that would solve global warnings and war issues. But then where’s the fun in that?

I sure learnt that everyone has different ways of interpreting different sources of information, especially when I went over my peer assessments. One person said everything was perfect and I needn’t change a thing, where as the other person was slightly over critical, even criticizing my posts on my high word count. Another example is when I got feedback on one of my posts (euthanasia) from an external reader and having him lay down his opinion and reasoning which contradicted mine. By him having another opinion, I actually ended up struggling to defend my own opinion as his argument taught me about so much I didn’t know. So how would we learn anything if everyone has the same opinion?

That brings me to my next learning experience. I have come to realize that there is still so much we don’t know about or have thought about discussing. These last few weeks has provided many interesting topics and conversation with fellow peers and family members. But there were only 5 topics, and I can promise you that isn’t enough to truly say you are now ethical because you tackled those topics. There are still so many undiscovered topics and arguments we still need to stumble upon. Even though this ethics course (and next year’s one), will give us some sort of background and base for developing and defending our ethical decisions, we still have so much more to research. What I mean is that once this chapter is closed, we shouldn’t just close the ethics module, pack it in a box and attempt to open that box when necessary. We should strive to continue questioning decisions, beliefs and opinions to keep us “ethically sane”. I really enjoy arguing, so I’m sure this might become a slight obsession of mine.

Lastly, after going through the previous topics, even though not all of them or strictly based on the health profession, there has been some health professional conduct undertones amongst them. Therefore, in discussing the topics, researching them and developing an opinion about them I have developed some sort of professional conduct and well as a personal one for myself. Having said this, it is something I have learned is important to keep separate. We may have many belief systems or opinions that we hold to a personal level but this is something we need to keep separate when it comes to treating our patients on a professional level. As mentioned before, everyone has different opinions, beliefs or morals therefore as a health professional it is not appropriate; never mind none of our business, to instill our own personal development on each patient. To underline that concept, we need to treat each patient according to their problem, taking into account their personal beliefs, respecting that and treating them accordingly. This is something I signed up for; hence it is something I need to respect.

With regards to deciding whether my expectations of this course have been met, im not sure I can really answer that question precisely. To be frank, I never really had a specific expectation for the course but rather just thought it would be us just posting about our ideas and feelings. So if I said it was above my expectations because I didn’t think I would learn so much about ethics, my peers and even myself, I may be lying because I didn’t really know what to expect? I kind of just thought I should go with the flow and try my best to keep up with the posts to get the course over and done with, but here I sit, a little wiser than 5 weeks ago. I think?

 

Going forward, I will take the three above mentioned examples of my learning into my practice. I will treat each of my patients individually, respecting their individual thoughts, beliefs and morals. I will respect the fact that I don’t know everything and I am going to find myself in situations that may question my ethics or morals this just means I need to keep myself above water by constantly preparing. Thus, I will maintain contact with ethical discussion groups to continue understanding opinions of others as well as continue researching about conditions I still don’t know and understand. This means I will be able to give my patient the best therapy possible. Obviously this can be an empty promise, but I will only be letting myself down at the end of day.

Now this can all be a load of bogwash that I’ve written here, or it can be my attempt to showing you what I’ve learnt. That is once again, your own opinion. But I honestly feel it’s a little difficult to physically show you in one post what I have learnt, because learning is something done within, at your own pace and is something you want. I cannot literally show you what I have taken from this course and you cannot tell me if I have done the correct thing.

Because this is all my own opinion and you have to respect that.