A Tough Pill to Swallow

As a community service medical officer in one of the most interesting health care systems on the planet, I’ve seen how easy it is to point fingers when we discuss its failures. For once let’s point the finger in all directions to find something resembling the truth: yes we’ve been set up but we’re also failing each other. (grab some refreshments, it’s a long one)

System failure sounds like an easy out so for once let’s talk about how each of us is failing: as professionals, as patients and the system that’s got us at each other’s throats while it crumbles around us (#Cleganebowl style). It’s been a while since we took a deep dive. I think I’m going to make it my life’s work to expand the narrative around health care to include more truth and humanity (at the very least it’s a promising side hustle).

There is a lot of misinformation and one-sided accounts out there. I can’t tell you how many Carte-Blanche episodes or scary health system ‘expose’ stories I come across that leave me puzzled and thinking: ‘how on earth could that possibly have happened?’ If you’re wondering, the answer is half, the other half of the time I’m shocked and embarrassed by the heartbreaking stories of negligence/horror alongside everybody else. I’m going to do my best to provide a balanced argument using a little bit of compassion for my patients and colleagues alike, a few scathing reviews in all directions and some self-reflection. Of course, in the interests of full disclosure, you should absolutely view this with the fact that I’m a black female UCT trained, urban-internship, rural-based South African doctor in mind.

Let’s start with a little bit of (simplified) background history: South Africa was an Apartheid state a quarter of a century ago. During that time, the majority of the country’s citizens (read: 76-83% as of census 1995) were denied basic freedoms and access to good infrastructure such as education, the power grid/electricity (see: Eskom cc loadshedding) and health care. All of which were excellent and functional and BUILT TO CATER TO A LITERAL FRACTION OF THE POPULATION so kindly leave any “things ran better during Apartheid” arguments at the door. Townships (at the time shorthand for low-level housing), often found on the periphery of every major (and minor) suburb, are a direct result of town-planning to provide easy access to a cheap labour force for white people so their comparative lack of infrastructure is by design. The Western Cape still has vestiges of this as the best running provincial health system in the country which includes still functional maternity obstetric units (MOUs), Day hospitals and Community Health Centres (CHCs) which function alongside clinics and in tandem with the referral system and local hospitals. In short Cape Town got the best inheritance health-wise (kudos are due for maintenance though).

At the dawn of our democracy sweeping promises were made including: “free Healthcare”. Hospitals and clinics were built left and right, care was relatively free and the Patients Rights Charter was drafted. Unfortunately, the supporting infrastructure, planning, staffing, and policy to support them was not put in place or rather it wasn’t put in place uniformly and well. This is good a time as any to state that Public Health is not my portion. Actually any job that keeps my hands (and All Stars) clean is not my portion. Also see: meetings and paper work. I’m a clinician, I like the human work and I almost wish I didn’t as this severely limits my future lifestyle (and salary prospects) as far as medicine is concerned. I don’t believe there are many ways to obtain honest riches in clinical medicine alone. *Unless you’re involved in cutting people (see surgery: which also isn’t my portion). Don’t tell me love isn’t blind.

The Patients Rights Charter is an excellent document. Also adopted around 1997 were the Batho Pele (SeSotho for People first) principles aimed at guiding delivery of services and goods to the public. As a document for service delivery it makes sense that it errs on the side of customer service. I believe the latter is a mistake only because, when it comes to health, it becomes a selectively interpreted document. Rights should be emphasised with their respective responsibilities and health should be recognised as unique entity were the enjoyment of the experience cannot be used as a proxy for quality (I’m not taking about those who have bullied belittled or taken advantage of by a health care care professional) although ideally that should be the case. Customer service functions on the principle that the customer is always right. Health care cannot be treated like an opt-in trip to the supermarket. There are various studies, experiments and anecdotal evidence to support the fact that patients cannot subjectively evaluate whether they have received good health care from a quality stranding (which is not the same as a pleasant interaction).

Sometimes getting good health care requires uncomfortable experiences of varying degrees of unpleasant-ness (from a finger prick and antibiotic associated discomfort to a needle in your vein/spine/bones/lungs; having fingers in intimate orifices and parting with bodily fluids) that if you can opt out of on the basis of your level of comfort, can be detrimental to your health and impede or ability to help. That is not to say people should not have am understanding and say in what happens to their bodies (autonomy) and the be empowered to refuse harm (non-maleficence aka “first do no harm”) . The rights enshrined in the charter are designed to protect patients from exploitation, degradation and harm. We still missed the boat when we erred in the side of customer service. The customer isn’t always right.

The people vs public servants
Let’s get to the painful honesty. I’ll go first. I am fallible human and make mistakes, I’m prone to biases and bound by my worldview and education (and the limitations thereof). Flawed comes with the human territory as does art and nuance. The only reason that we can’t delegate medicine to robots is because medicine needs a bucket load of both and, you know, humanity.

I’ve met, worked with, been taught by, worked under and taken orders from aborrhent humans who call themselves health professionals. Unkind, lazy, negligent, outdated, bitter, bigoted, racist, inhumane people. Pick a word or pick a combo I’ve worked with/for/under them. I’ve been some of those things on occasion too. I’ve witnessed patient assault firsthand (verbal and physical) and I’m not proud to say that I didn’t report every single incident. I’ve seen patients forced to stew in unspeakable conditions and while I blame “the system” I know in my heart that some of it could have been avoided. I’ve had opportunities to potentially make a difference and found my courage lacking, accepting instead that “I’m a junior they won’t listen”. I’m intimately acquainted with the toxic work cultures that we perpetuate: how we talk to, belittle and berate one another, the example that we set for medical students (and the sometimes poor treatment we subject them to, poisoning the well fit the next generation) the arrogance, entitlement, elitism and the God-complexes.

I know what it’s like to yell “resus!” and be told “it’s tea time dokotela” or to hear “my hands hurt” when instructing someone to start CPR when a literal life is at stake. Apathy is a scourge upon my profession and it grows (and should be treated) like a weed. I say all of this to acknowledge that sometimes the horror stories are true and sometimes it’s not the system, it’s us. I’ve born witness. We are not blameless.

The public servants vs the people (alt title: “I pay your salary”)

Of all the pills I’ve prescribed I’ve found Responsibility to be the pill patients find most difficult to swallow.

Let me start by first acquainting the public with my degree, the MBChB (or MBBCh if you went to Wits): it’s a 6 year constantly evolving course that is aimed at (and in truth, sometimes falls short of) preparing one for the South African context which is a wild west of 1)diseases of lifestyle (first world), 2)communicable diseases (thrid world), 3)the HIV epidemic and 4)interpersonal violence (see: trauma, GBV,mkfor vehicle crashes) known collectively as the Quadruple Burden of Disease, a cocktail serves cold on the Southern tip of Africa. Throw in 11 official languages (and almost double that number of cultures) and a people struggling with in disenfranchisement or poverty and we have ourselves a party. The degree is a heady mix of hard theory, practical clinical skills and cultural competency.

And at 1am in the morning it boils down to this: years 1-3 address the what makes you sick? 3-6 adress what that looks like and how to help and years 1-6 try exceptionally hard to fine-tune my ability to answer these 2 questions: “are you sick?” And “can I help you or should I send you to someone that can?”.

A pilot wouldn’t expect me to know how to fly his plane, its not my scope of practice and insults his/her qualification. I do expect a level of professionalism and confidence to reassure me that s/he can fly the plane but you will never find me in the cockpit with a Wikipedia article titled “how to fly a plane”. In my case against the people I will outline the misuse of rights and the danger of entitlemequotet without responsibility.

We’re in such a rush to call our people helpless thus making free Healthcare a no brainer. Poverty does not a fool make, If anything people can be shrwed as Slytherins while we’re busy peddling the Innocent Helpless Victim narrative. While there are several humans in dire need and many more who are lovely and responsible patients that make me happy to wake up every morning, this case isn’t against them. Our people can be entitled. A regular occurrence: someone demanding that I speak their South African language of choice “ngiyakhuluma” (I’m Sotho) but swiftly find their English for my white colleagues and call me sister in the same breath (I always try to introduce myself or wear a name tag, it’s one of the rights in the charter).

Our people can be lazy and exploitative and surprisingly observant. They don’t want to pay for anything but abhor queues. They see us rush to patients arriving in ambulances on stretchers and resolve to never queue again. In the middle of the night, it is my job to be on standby for any and all emergencies and I’d gladly (reluctantly) be kept up by people in need but this is seldom the case. The misuse of emergency service is seldom accidental, it is wasteful, unhelpful and counterproductive:

Exibit a. Drunk patients calling ambulances post-groove as a a “free ride” home (which happens to be near the hospital) is abuse of essential resources. Bonus points for those who have caught on that alcohol mimics and/or coexists with brain injury and are thus guaranteed a warm bed overnight to sleep off their babalas before ripping out their drips and absconding in the morning.

Exhibit b. The wily queue jumpers who, in order to avoid the long clinic lines, call EMS (Emergency medical services aka ambulance/paramedics) at nightfall because they know they’ll be seen quickly “because they came with the ambulance”. Bonus points for those on chronic medication while learnt that omitting the morning dose will give us something to find to avoid a mild scolding for wasting resources.

Exhibit c. The unluckiky caught. There is a husband and wife duo that has had the misfortune of trying their monthly scam to get hassle-free medication on nights that I happened to have been on call. The husband has epilepsy and claims that he doesn’t have the means to collect his treatment at the local clinic once a month. So he doesn’t take his treatment for a few days, inevitably fits. Boom, ambulance = speedy treatment. Fun fact: because after hours is emergency time, there are no chronic patient files available. So unless the morning shift notices the pattern, there’s no paper trail to their shenanigans.

Exhibit d. Non-emergencies like your mild headache from last year, pink eye from 2 days ago, sore throat from last week, genital warts from 2017, the healthy 17 year old calling their muscle stitch “chest pain” (me: did you go to the clinic? Patient:”no doctor” ) cannot be managed emergently. 24 hour centres keep emergency drugs on hand. The pharmacy is open during daylight working hours ie. Tomorrow/Monday therefore your overburdening emergency services isn’t even yielding positive results. Go to the clinic hle.

For the above examples and many like them, the enforcement of other people’s rights to emergency care is their enemy. What inevitably happens is that they all think they’re the first to come up with these clever system loopholes and thus flood casualties preventing actual emergency care. As a result we have to triage (a system that allows us to assess and prioritise patients according to severity and limited resources ie. Who gets seen first). This process is often met with a sudden loss of humanity from the bedside experts when the dangerously bleeding wo/man who ‘just got here!’ gets seen first. “I’ve been waiting x hours!” they’ll yell, never acknowledging that the ridiculous wait is a product of their own making. Fun fact: if you have the brain power, wherewithal and lung capacity to yell at me, you’re highly unlikely to be an emergency. Not impossible but unlikely.

Our people can be cruel and violent. I’ve been threatened with a knife point in casualty by a non-psychiatric patient, I’ve been slapped by a family member that wasn’t even in the room when I saw my patient and as I raised my fists to defend my self, felt the flash of multiple phone cameras trained on me. I’ve had every bodily fluid known to man hurled at me, I’ve been bitten and scratched, verbally abused and humiliated but who do I complain to when the outcome of any encounter with hospital management (for a patient) has to end in, and I quote “an apology and explanation and a positive encounter”? “it’s the the job” people say. It’s not the job. Any job that requires this is a System failure. I love people, I love science, I love detective work, I love being a clinician. My passions are best suited doing my job not withstanding trauma.

As with most court cases, I’ve neglected to include any compliments because that’s not what makes the news. It’s all my mudslinging and finger pointing. Sit in this negativity and think about why health care workers are guilty harbingers of doom in the court of public opinion: it’s because you’ve consumed a steady diet of vitriol and one-sided negativity highlighting our worst failings with our humanity conveniently excluded. (for lighter more positive chats see my Bara Snapshots series and the keep an eye open for more positive future posts). You shouldn’t have to personally know a gratitude professional to get this. My name is Dr Ntoetse Lerotholi and I’d like to be excluded from this narrative (slim chance, but it’s my non-blog).

The public AND people vs The System
My CEO loves to tell us about government quality standards and how the province is broke because 50% of the budget had gone to “your salaries”. Because its easy to scapegoat the professionals. Build more hospitals and medical schools? And who will work in them when you’re freezing posts? The professional to person ratio is one of the most uneven in the world; We need more doctors/nurses/allied professionals/specialists, don’t leave the country: but you’re freezing posts (the phenomenon is the same as paper Towns where, on paper, there are 25 posts but only 5 of them can actually be occupied by living humans). Doctors are ungrateful, crying to newspapers about not being placed for work/being overworked: but you’re freezing posts. Your government passed a law they have no intention of enforcing by capping the maximum working hours of a health professional because noone can do heavy brain (or physical) work on minimal sleep (not to mention that people are encouraged to sue our pants off should we make any mistakes or “improvise” which is to say, deviate from treatment protocols): but essential medications and equipment are out of stock, generators malfunction, there is sometimes no clean/water and YOU’RE FREEZING POSTS.

As if we, as a country are not one of the most generous spenders when it comes to the national health budget allocation, as if it’s not statistical fact that most public health funds are squandered by mismanagement not scarcity. You’re fighting the wrong battle. All this while forcing health care professionals into conditions where we have to give substandard care then publically vilifying and using us as scapegoats for your failings. No amount of passion can bridge this gap and no amount of passion is meant to. One sided narratives are dangerous.

The thing I hear most health professionals (that I respect) bemonan, myself included, Is how we wish we could do right by our people “I wish I could spend my time actually doctoring”. I would like to have a 10min conversations about diet, exercise and unpack your mental health with you (see: rights) but I’d also like an engaged patient who doesn’t just nod when I’ve spent 5 minutes explaining their condition to them in their home language (with diagrams) only for them to tell me they have “places to be” and can they just “get your meds now”, especially “the pink little ones” (this person will inevitably leave my room and tell the sister s/he doesn’t know whats wrong with them, see: responsibilites). Regardless, this scenario isn’t always possible when there are 40-50 people waiting outside my door to be seen; who hiss at me when I try go pee. I usually spend the first six months in any new work environment not even knowing where the staff bathrooms are before I get a grip and prioritise my humanity ie. Bathroom breaks. The 40-50 people outside want to tell me How they’ve been sitting all day and pay my salary. Then someone from quality control will come lecture me about waiting times because your government has mandated contradictory protocols : Noone can be sent back to the clinic/you must only see 30 people/nobody should wait more than 2 hours/everybody must receive a detailed (read: time consuming) consultation.

For all the emphasis on rights I never hear anyone else lecturing patients on their responsibilities (trust me, they don’t like the latter). I think ones ability to value something is impeded when a) one feels entitled to it and b) it is free; one woman’s opinion. Everybody knows that they have the right to not be refused but neglect to learn that this applies to emergency care and that we reserve the right to redirect you to the appropriate level of care if it isn’t. I believe that the customer service model has allowed people to neglect their responsibilities and dejected know their rights (or honor your responsibility because it’s easier to lodge a complaint, or better yet tell the papers that they turned you away (conveniently omitting that you refused the alternate option given to you) or that we decapitated your baby (neglecting to mention that the child was declared dead in-utero and came out in, admittedly horrifying, pieces) and spreading far and wide that people die at hospital x, leaving out the fact that you brought them to our door with a CD4 count of 2. One sided narratives are dangerous.

Verdict
I sometimes feel like I’m being asked to watch people die on my watch. When the management of a condition requires ABCDE and you have B, C and D out of stock, we’re fucked. Why not improvise you ask? That’s literally my job description (read: not my job description). I don’t know when last I performed a truly sterile procedure outside of an operating theatre or how often I’ve been laughed at for requesting equipment that I last saw in medical school. But should anything go wrong I’ll be asked why I didn’t do it “properly”. People tell me to leave, I really don’t want to. But I get why people do and therefore I don’t have words to ask people to stay: In the public sector, in the country, in the profession. It’s not what we signed up for. The stories we tell about each other matter. We’ve allowed the the government fail us and have resorted to fighting each other. I have suggestions but I’m not a politician so I do what I can where I am with what I have (for now its my oesonal corner of the internet).

If you learned that after undergoing extensive dance training, that being a ballerina suddenly involved having your legs tied together 50% of the time and arguing on the phone/filling out paperwork to ensure that you can actually dance every 3rd Sunday of the month ,you wouldn’t be so quick to tell the dancers: “that’s the gig”. You’d have questions because it’s heartbreaking. So now you know and I hope you take all sides into account when you make your judgement. As for me: I love to dance and those few minutes when I actually get to do my job I feel like flying but I shouldn’t have to break my back to do it. Let us dance or let us go. Let’s all do better by each other and tell the truth the whole truth and nothing but the truth. Please help me God.