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Compassion at the crossroads of quality improvement in Africa: Are we speaking the same language as the receivers of care?

By Louis Ako-Egbe
on August 31, 2018

In my later years as a medical student, I was fortunate to take calls in a local clinic in the neighborhood of my medical school – University of Buea, Cameroon. Still struggling to finetune the clinical skills I had learned through my training, making sense of clinical presentation of diseases, prescription of medicines and para-clinical investigation requests and interpretations were still a huge challenge to me.

Then one day, I received this 62-year old lady in my consultation room with a longstanding history of hypertension and Diabetes Mellitus (Type 2). She had traveled widely for her health problems within and outside of the region and had been seen by many physicians, GPs, and specialists alike. She had 4 consultation booklets full of histories and prescriptions. Confronted with this I was completely lost on how and where to start addressing her problems.

To begin, I used about 3 minutes to flip through the pages of her many medical booklets. Later I gave her the moment to express her concerns on the onset of her illness and how she had been struggling with it. She had my full attention because I was very keen to understand the root causes of her predicament.

The old lady narrated her experience with these chronic diseases while I patiently listened, and like a clueless investigator seeking for answers, I probed with questions inspired from perusing her booklets earlier. At the end of this exchange, behold, the old lady broke into tears before me. I was so embarrassed thinking I probably asked a wrong question or insulted her in a way ignorantly.

When she was calm and stable again, I asked her curiously why she had reacted the way she did. She told me, “My son, I have been to so many doctors, some specialist and far older than you are. But none of them has ever taken the time to listen and talk to me the way you just did”. I didn’t know how to interpret these words and the emotions around them. First, I had a feeling of fulfillment that I was on the right path to my calling as a medical doctor, but later a feeling of empathy and grief followed because I myself have also lost a loved one to the same health system ‘s insensitivity to the needs of its patients.

As I reflected on this experience in the course of my practice, I felt that maybe I had a lot more time to listen to this lady as a medical student than a full-blown GP or internist. However, as I reflect deeper I realize my keen interest to listen to her so passionately was motivated by the feeling of empathy and curiosity to find solutions to her problem. Put differently, I showed ‘compassion’ – the humane quality of understanding suffering and wanting to do something about it. Besides the complex nature of her case, the impression of ‘incompetence’ on my part to single-handedly address her problems was even more preoccupying. Therefore, I felt compelled to follow her story to understand the evolution of the illness, identify her concerns and preferences for care.

In my experience in clinical practice, most practitioners fail to see this complexity in patients’ complaints. We have simplified them to “cases” with standard management protocols and guidelines to such an extent, that the moment a patient starts giving his/her complaint, the health professional quickly sums up the syndromes into a diagnosis, “Oh! This is another case of PID or diabetic neuropathy or stage 3 hypertension etc.”, and a list of investigations and a potential management plan already inscribed follows. This one-size-fits-all approach in medical practice has many limitations. Therefore, it is not surprising to note that diagnostic accuracy is wrong in about 40% of medical cases and that medical errors remain frequent.

This syndromic and case-oriented approach to medical practice is partly the result of the emphasis of medical curricula and training. The reductionist (simplistic) approach of the biomedical model, that focuses on germs and how they alter the human system, has not paid enough attention to the role of society, cultural and personal behavioral practices on the disease and its curative process. This view is perhaps changing now with the emergence of non-communicable diseases. By and large, however, standardized protocols and guidelines are still the mainstays in today’s clinical practice.

Most clinicians find it very difficult to divorce the arts of clerking and summarizing patients’ problems as cases, memorizing management guidelines and talking to “cases” rather than persons during ward rounds. These attributes emanate from our training and how we observed our professors in medical schools refer to patients by the names of their diseases. But the question is, can patients’ perceptions, expectations and needs also be standardized?

In some of our settings, quality has been reduced to the technical effectiveness of healthcare in the form of presence and adherence to clinical protocols, the use of modern technology and state-of-the-art equipment, among others. Am I saying that emphasis on technical effectiveness is wrong? Of course not. Incompetence in performing a Caesarean Section or poor management of a postoperative patient who ends up septic is a characteristic of bad quality healthcare. However, the technical effectiveness of care should not be void of compassion, rather both should be integrated and complement each other. My 62-year old patient could not understand the efficacy of antihypertensive and antidiabetic regimens, all she needed was a good listener and an empathic care provider. This was quality to her and to a host of others who visit our hospitals every day.

If the technical dimension of quality in healthcare is the cake, then compassion is the icing/cream on the cake. To echo the words of Tom Shakespeare in a BBC news article, “We need health professionals who are technically competent, but who can also demonstrate the virtues of compassion and empathy…”.

I believe that our greatest responsibility as health professionals in improving the quality of healthcare today is to be able to “decode” the perceptions of quality care by the beneficiary population. We need to acknowledge the uniqueness of people and their concerns and not define and manage them by their cases (diseases) only. At times, they just need someone to talk to and not necessarily a prescription. Until we begin to speak the same language of quality with the consumers of healthcare services, we shall continue to serve the cake without the cream.

So far, 2018 has seen an increased focus on quality in healthcare delivery. A report on delivering quality services was published recently by WHO, WB and OECD, and the launch of the Lancet Global Health Commission on High Quality health systems is scheduled for next week (6 September). Recently, WHO also launched a co-development call to explore ‘Compassionate Healthcare’, “the human aspect to improve quality of care”.

Let us hope that through these milestones we shall pay enough attention to the cream of the cake as well.



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Njilla Steev says:

I am reading this article 3 years after it was originally written and I am totally fascinated. Great writing.