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A Look at the problems at IGMH - always room for change

By a Doctor - Male', Maldives - Monday, June 07, 2004 - OPINIONS expressed in the article are that of the author only.

This is a feedback response I wrote to the article: http://www.themaldivian.org/dhivehi1.htm

Finally I read a good article on the site.

I am a doctor who works at IGMH. I also have several issues that I have raised with the Hospital administration from time to time to improve the practices and to improve the quality of services.

I would like to thank the author of the article addressing the services at IGMH. He has very rightly pointed out that things need to improve. There is always room for improvement. More so if things are not going well.

I would also like to comment on some of the points raised.

The situation in the Labour Room.

The arguments regarding the delivery "cut" is a genuine one. The cut or episiotomy is a cut given to the female genital to allow for the delivery of the head of the baby. It is a universally recognised obstetric procedure.

It can and should be used to allow for delivery of the head of the baby when it is known that the head is large in relation to the opening, if there is risk of delay in birth, if there is need for instrumentation.....etc.

However, the real issue here is not that "cuts" or episiotomies are performed. My concern is that it is performed in ALL mothers delivering their first baby, regardless of the size of the baby or size of the birth canal. In cases when it is not the first baby....if there was a "cut" in previous pregnancy....then again a "cut" is given. Which means that they will all get the "cut".

I did some reading and found out that statistically about 10-20% of first time mothers would actually require a "cut". The other 80% who are getting it don't need it.

The reason why many obstetricians at IGMH advocate the "cut" is because it will prevent a tear. But again recent and even not too recent evidence shows that a tear heals better than a "cut". If they say that a tear has a higher chance of causing injury to the anus....evidence shows that the risk is less!

I have talked to many of the nurses in the Labour room. And I have found out that they are told to give the "cut" anyway. If they didn't then some of the senior doctors would actually blast at them.

I have to say that the nurses are actually much better than they are pictured in the article. I would say that whatever good that is actually happening in the Labour Room is because of the nurses.

There are student nurses in the Labour room. But they need to be there. I don't think that they behave disrespectfully while they are there. It is true that the nurses engage in conversations while a mother is giving birth. Maybe it helps them to keep calm in the stressful condition....but they do need to control it.

The Labour Room nurses would also like to have more nurses working in the Room, sometimes there are far too few nurses to care for the many mothers in labour room. Over all I would say that the nurses do a better job than the doctors in Labour Room.

Regarding Doctors having to take orders from nurses.

Some of the nurses in the Hospital are highly experienced. Some of them have been working as nurses (and doing a good job) since before I learned to walk.

It is a good practice that doctors take advice and opinion of nurses who are more experienced than themselves. This is also true because it is the nurses who actually look after the patient, and they would usually develop a better rapport with the patient and the relatives.

Nurses are the best working partners that doctors can have in the hospital. In this regard their opinions and advice are invaluable. I have never been pushed by any nurse to do something that I didn't want to do. I haven't heard of anyone having been forced either. It is the doctors decision. And if the "order" is something that harms the patient then it is the doctors duty not to "obey" it and in fact report it.

It is also important to note that it is the nurse who actually delivers the treatment that is prescribed by the Doctor. In that situation they are responsible for the medication that they give (they have to check if it is the appropriate medicine and at appropriate dose). I have been approached by many nurses who actually are concerned about doses of medicines prescribed....just to check if that is an appropriate dose. That is a good thing, and I would always support that level of commitment.

Don't get me wrong, all this doesn't mean that ALL nurses are good....there are some who are not good enough....but there are some who are extremely good. I would actually be more comfortable leaving a relative in the care of some of the nurses than doctors.

Regarding the "Manager".

I second that opinion. I also believe that the person who is given the responsibility to run the hospital, if possible, should not be a clinician. Unfortunately there aren't many people willing to present themselves to run the hospital.

Hospital Management and Administration is a field in itself and we need people trained for that. I am surprised at times how things are mismanaged....it is as if they say that this is the best possible anywhere.

Regarding Caesarean Section.

The C-Section rate in IGMH is high, but I can understand the reason why it is so. From the discussions with Obstetricians at IGMH over the year I have found that it is because they want to improve the outcome of the pregnancy. This is a genuine feeling.

It is NOT improving skills! No doctor gets a kick out of having to open up a patient surgically.

This does not mean that all C-sections performed are actually needed. Some of them actually don't need that surgery. However many of these unnecessary C-sections are because of patient preference. (there are cases where the patient preferences, and requests for C-section are disregarded on medical grounds or otherwise).

Regarding the communication gap between doctor and patient/relatives.

This is another Major issue. Many times the biggest problem in IGMH practice is this gap. And the people that cause this gap to widen. Some doctors actually "tell" the patient/relative instead of "explaining". I have been told by many patients and relatives "nobody had previously explained it to me like that". Some doctors don't find the time (or are actually unable to find time) to actually talk to the patient or relatives. This is particularly true when the patient is very sick. The main reason being that the sick patient requires the doctor to be there with the patient than with the relative. But another reason is that at times the doctor or team of doctors don't know for sure what is happening...or are unable to explain the events on medical grounds. This is possible...and it doesn't make that doctor or the team of doctors less capable....it just is not possible to know everything. To accept this fact and to actually say so is important (and hope that the relatives understand this).

The ICU is a place where the most sick patients are kept for care. This is the place where the most miscommunication occurs. We need people who can communicate well (other than doctors) to be placed in an easily accessible place and with enough knowledge to explain and understand the relatives need to know the condition of the patient.

The Public Relations Officers or Co-ordinators (although not all of them) are useless in this regard. I would say that they make the matters worse by antagonising with the relative or the doctor. They are not helping the relatives by blaming the doctor (which they frequently do...to appear good in the face of the relatives...and to maintain their public image).

I think a lot of the issues will be solved by having clearly written and explained policies in the Management of illnesses, rather than service statements and statements calling for everyone to use deodorants! If the doctors know clearly when a "cut" is needed and when C-section is needed in the form of written hospital protocols and policies then these written documents can be communicated to the patients and relatives well in time so that they may accept them. The relatives and the patients would then know that this is a standard practice and good practice based on evidence and experience.

We don't need the seats in the OPD and IPD to be changed every 2 months. We don't need the colour scheme of the hospital walls to be changed every 3 months. These cosmetic changes make the place look better. That is good. But we also need to improve the services.

Looking forward to better days.

NOTE: I expect the Hospital admin and the MOH people to call all the doctors collectively or individually to find out who wrote this. They will spend many hours thinking of how to punish me for this. Only if they will spend time and effort to improve the hospital! I will continue to work at IGMH and try to make a difference.

Thank you again for letting me give the feedback.