University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions
Overview and Instructions they feel they ‘have given in to the patient’, or ‘the consultation didn't
During the family medicine lecture week, you are expected to complete
this self-study. For the self-guided readings, you are expected to:
1. Read the material provided before the relevant lecture.
2. Answer the questions at the end of the reading (if present) before
the related lecture:
a. As a guide, answers should be ~3-4 sentences, maximum.
b. The purpose is to stimulate your thinking, not to make you
write a long essay.
3. Note: “further reading” section is not mandatory, but encouraged.
4. You are expected to bring your answers with you to class.
This reading and the questions are designed to help you to gain a deeper
understanding, and learn more about a particular issue of relevance to
Family Medicine. Completion of the exercises will enable you to gain
more from the lectures through preparation and thoughtful processing.
Each guided reading exercise is designed to take you no more than one
hour to complete.
We hope you enjoy your introduction to some Family Medicine topics
supported through these guided reading exercises.
Guided Reading # 1 – Models of Family Medicine Consultation
Article: Clark J. The narrative in patient-centred care. Br J Gen Pract. 2008
Dec 1; 58(557): 896. Link:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2593554/
Practicing patient-centred care brings many benefits for the patient. It
enables them to be heard and their ideas, concerns, and expectations
addressed. For the doctor it is less clear. Registrars sometimes tell me
Page 1 of 21
achieve what they had hoped.’ Of course with experience we realize that
a consultation needs to involve negotiation if we are to connect with the
patient and reach agreement. We also realize that things often take more
than one consultation and following patients is a real strength of our
general practice. If, during a consultation, we achieve a new
understanding which empowers the patient, we all feel satisfied.
Furthermore, when that great consultation happens I suspect we all know
we have connected on a deeper level with emotions and maybe even in a
spiritual dimension. This is my great reward as a doctor.
Watching newly qualified doctors early in their training I don't feel many
achieve that ‘great consultation’. This is mainly because they need to
make sure that they are not missing serious treatable physical illness.
They rely on using questions and answers to work towards a truth, a
dialectic method. This method is encouraged in medicine and of course it
has an important part to play, but connecting with and understanding a
patient requires the doctor to appreciate their unique perspective. This
unique perspective is expressed through the patients' narrative, which
doctors all too often see as a distraction from, ‘getting to the bottom of
things’. Conversations with registrars about their consultations confirm
this when they say: ‘they wouldn't let me ask what I wanted’, or ‘they
were only interested in telling me their story’. Trying to help registrars
appreciate the value of the patient's story is difficult when the focus is on
black and white truths.
At the last South Bristol trainer's workshop, I was strolling along the soft
Saunton sands and sharing stories when we stumbled on a metaphorical
insight into narrative. One of the trainers was talking about golf and said
he had hit a hole-in-one but was on his own. The ball sank into the hole
leaving him feeling rather empty. If only someone had witnessed it! The
patients' narrative is rather like a hole-in-one, it needs to be witnessed to
give it meaning and increase its value. Telling it to the doctor means it is
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions
witnessed and validates it. Rita Charon talks about the narrative as a
singularity, ‘what distinguishes narrative knowledge from universal or
scientific knowledge is its ability to capture the singular, irreplaceable, or
incommensurable.’
Witnessing the patients' narrative is an important part of a good patient
centred consultation; their narrative is unique and it connects us with
their way of seeing the world. This is an important idea because patients
and doctors see the world in differing ways. Immanuel Kant understood
this. 2 Before Kant it was thought that we were all passive receivers of
information about our world and therefore we all see the same things in
the same way. Kant however said that the world we live in and perceive
depends on our individual experience and the qualities of the perceiver's
mind rather than it existing independently. As a result we all perceive
things differently and reason alone will not give us the nature of someone
else's reality. We can tell one patient that they have irritable bowel
syndrome but this same advice might mean something very different to
another patient (or even another doctor!). The patient's understanding is
built from their knowledge but also requires their sensory experience and
concepts which means we must listen to the patient's story if we wish to
help them.
Therefore it follows that reason, logic, and direct questions cannot be the
only guide in a consultation. Doctors need to weave knowledge into the
narrative if the patient's understanding is to be appreciated and changed.
Understanding on a philosophical level is not simply reconstruction but a
mediation of the truth.3 Negotiating this truth could involve using our
own narrative, using rhetoric ourselves; the patient has a narrative but so
does the doctor and we could enlist this in our tool box to explain things
to the patient. Involve the patient in a story. Playwrights have known this
forever! Shakespeare didn't just write; ‘Romeo loves Juliet who is from a
different feuding family. In a moment of confusion when he thinks she is
dead, he accidentally takes a lethal poison and she is heartbroken.’
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Instead he wove a tale and took us on a journey. Our message would
have much more impact if we entertained the patient with a story. This
way our information is memorable. We are, after all, educators and as BF
Skinner says ‘Education is what survives when what has been learnt has
been forgotten.’4 Saying to the patient ‘you must stop smoking’ might
work but how about using a little tale and fixing it into their narrative;
‘you were telling me earlier what happened to your dad because of
smoking? It would be a shame to give your kids the same memories,’
The consultation is better for narrative; it is greater than a direct
questioning approach alone. Consider this; think about going to a film of
your favourite book. The film is never as good. The film tells the facts but
the book is the real narrative, emotion and imagination. In a similar
fashion, clinical medicine tells the facts but the narrative contains the
emotion, opportunity to use imagination and real unique meaning for the
patient. We would all like our doctors to have ‘seen the film’ and know
the facts. But I think we would all like them to listen, ‘read the book’ and
engage with our story.
Questions:
1. How does the writer describe a ‘great consultation’? Describe what you
think of as a ‘great consultation’.
2. After reading the article summarise your understanding of the meaning
of ‘patient centred care’ in family medicine
3. The writer constructs a brief story to help a patient stop smoking.
Construct a similar story (maximum 5 sentences) about some behaviour
change advice that you might use.
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions
Further reading:
1) Pages 5-8: The College of Family Physicians of Canada, Working Group
on Curriculum Review. Website:
http://www.cfpc.ca/uploadedFiles/Education/CanMedsFMEng.pdf
2) Dr Harvey Chochinov. Dignity and the Essence of Medicine: the A B C D
of Dignity conserving care
Website: http://www.bmj.com/content/335/7612/184
Comments from Further Reading:
Guided Reading # 2 – Impact of Family Physicians in the District
Health System
Selected Excerpts from the Article Article: Swanepoel M, Mash B, Naledi T.
Assessment of the impact of family physicians in the district health
system of the Western Cape, South Africa. Afr J Prm Health Care Fam
Med. 2014;6(1).
Link: http://www.phcfm.org/index.php/phcfm/article/view/695
Page 3 of 21
Introduction
South Africa is following an international movement towards
strengthening primary healthcare (PHC) services. This is being done in an
attempt to improve the health of the citizens and reduce the cost of
health care delivery. In South Africa, strategies for improving PHC and
district health systems are being explored. The current national health
insurance (NHI) roll-out has set the re-engineering of PHC as a priority.
In 2007, the discipline of family medicine was recognised as a new
speciality in South Africa, and as a result the eight South African medical
schools changed their existing degree programmes to Master of Medicine
(MMed). The Department of Health created full-time registrar training
posts with family physician supervisors. The first MMed-qualified family
physicians graduated in 2011. In the Western Cape Provincial Health
System, 21 family physicians were employed in 2011, 32 in 2012 and 42 in
2014. It is expected that this number may increase to 60–80 over the next
5 years.
Nationally, there are 52 health districts, of which 6 are located in the
Western Cape….In the Western Cape, the Department of Health
committed to establishing family physicians in a central role in the District
Health System (DHS), particularly at the district hospital, in order to
improve patient outcomes. They do not provide first-contact care, but
capacitate and support PHC teams in a clinical and mentorship capacity.
They are custodians of clinical governance, provide leadership, and are
catalysts in implementing community-orientated primary healthcare. The
roles rest on the foundation of academic and clinical knowledge acquired
within the new family medicine postgraduate curriculum.
Aim and objectives
The aim of the present study was to explore the perceptions of district
managers on the impact of family physicians in the Western Cape.
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions
Specific objectives were to:
1. Explore the perceived effect of family physicians on health system
performance.
2. Explore the perceived effect of family physicians on clinical processes.
3. Explore the perceived effect of family physicians on health outcomes.
Methods
Study design
This was a qualitative study using in-depth interviews.
Setting
The present study was conducted in the public sector of the DHS of the
Western Cape.
Selection of participants
The managers of each of the rural districts and urban sub-structures in
the Western Cape were selected for participation in the study, based on
their broad scope of knowledge of the functioning of the DHS and
overview of the impact that family physicians have made. In addition, the
chief directors of the metropole (four sub-structures) and rural areas (five
districts) were also selected.
Data collection
In-depth interviews were performed face-to-face in the interviewee’s
office using an interview guide, and ranged from 60–80 minutes.
Results
The study population consisted of nine interviewees, as described above.
Three of them were male and 6 were female. All were middle aged (> 40
years) and had at least 5 years of experience in healthcare management.
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Roles of the family physician
The family physicians were perceived to have raised the clinical levels of
functioning in the DHS, in terms of management of clinical emergencies,
consultations on difficult cases and guidance to juniors to work more
efficiently in terms of time and resources. They have taught juniors how
to do ward rounds quicker and they have run specialist family physician
clinics. Their seniority has given them the necessary authority to
communicate directly with other consultants and senior managers:
‘You know it is just that seniority, that clinical knowledge, the
more kind of decisiveness about what it is to be done.’
Clinical proficiency is the foundation for effective clinical governance, and
family physicians were seen to be well suited for this function in the DHS,
based on their comprehensive clinical training and the ensuing higher
level of clinical reasoning. Regular morbidity and mortality meetings were
held and recorded. Clinical audits to improve quality of care were done by
means of folder reviews: ‘As a family physician she brings in the clinical
governance oversight. So it’s very much on clinical proficiency and
whether you’re making the right decisions.’
Clinical processes
Family physicians were perceived to provide leadership for the campaign
against diarrhoeal disease and helped co-ordinate activities. They
identified the desired clinical outcomes and the appropriate course of
action for each category of sick child in the diarrhoeal care pathway:
‘So there’s a system that’s put in place, but there’s also that senior clinical
decision making that’s there and I think the diarrheal season is a great
example of that.’
Respondents felt that the Integrated Management of Childhood Illness
(IMCI) programme was impacted by family physicians, but the impact was
limited. Those family physicians that had a clear understanding of the
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions
IMCI programme provided support and in-service training to nursing staff
in order to attain better outcomes.
Family physicians impacted positively on chronic disease management
through clinical leadership and direct patient contact. They tended to
think more holistically in terms of patient care. A particular family
physician developed a risk stratification tool that was implemented in one
district and used in the day-to-day care of non-communicable chronic
diseases. This tool enabled trained healthcare providers to easily stratify
these patients as either stable, at risk or decompensated according to
appropriate clinical criteria applicable to each condition, and respond
accordingly. These patients would then either continue with routine
chronic disease care, or intensified chronic disease care, as characterised
by more regular visits and special investigations, or by transfer to the
casualty for possible admission to the hospital. This tool was later
commissioned by the Western Cape Department of Health and piloted by
several districts during their chronic disease drive.
Their inputs helped to integrate systems across a range of chronic
diseases, rather than focusing on specific diseases:
‘I think the success is that we took a clinical governance
perspective and not a programmatic perspective in implementing
the chronic disease management plan. That to me it is really a
strength and I think the family physician involvement there made
a huge impact.’
Family physicians also had a significant impact on the care of patients
with HIV and TB. They were seen as chipping away at the vertical nature
of theHIV care model and providing a more holistic approach to patient
care:
‘When she approaches chronic diseases she approaches it
systemically. From where she’s sitting that all chronic disease has
got something in common and the systems that you put in place
Page 5 of 21
for good outcomes for the client is a uniform way of doing
things.’
One family physician conducted a quarterly anti-retroviral (ARV)
morbidity and mortality meeting and used this to capacitate nursing staff
and doctors. She also communicated with the district office about routine
ARV data, identifying the need for resources allocation and training gaps.
Maternal care in the metropolitan sub-structures was almost exclusively
run by obstetricians, but in the rural districts maternal care was the
domain of the generalist. Quality of clinical care at family physician
managed facilities in the metropolitan areas was seen as on a par with
other facilities of the metropolitan area. One family physician was tasked
with improving prevention of mother-to-child transmission (PMTCT)
rates. Good antenatal care practices were implemented and PMTCT rates
dropped:
‘So it’s had a massive impact which I don’t think we are capturing
fully in that there’s a story to be told about the impact of family
medicine on the Midwife Obstetric Units, because I think it has
been positive.’
It is recognized that the majority of patients with trauma and medical
emergencies in the metropolitan area presented to the 24-hour
community healthcare centres. The clinical governance and leadership
that family physicians provided to medical officers in the emergency
centres impacted indirectly on emergency care on a large-scale:
‘You know the family physicians take pride in the fact that they’ve
actually with the full-time doctors, with the cosmos, with the
general medical officers that work there – they have
systematically improved the outcomes and the clinical decision
making and the impact.’
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions
Patient satisfaction was affected directly by the intervention of family
physicians. Respondents reported that family physicians were perceived
by both staff and patients to be knowledgeable, senior and empathetic:
‘The child died at birth or just a few minutes after birth but the
way in which the family physician and the staff supported that
family was very positive. So it actually prevented the department
from, you know from a legal case.’
Coordination of healthcare services in the district was also positively
impacted by the family physician in many aspects:
‘I think the most important thing for me is really the person
placing themselves at the centre of a team. And you know it’s
being at the centre of the team with a purpose. Being patient
centred with a population outcome in mind.’
Family physicians impacted the referral system by means of appropriate
improvements, such as training nursing staff at the clinic level to perform
appropriate patient work-up prior to the referral. These family physicians
were also perceived to be good at referring patients themselves as they
know the referral routes and have more authority as a specialist.
Unanticipated effects
Family physicians were involved in meetings related to clinical
governance but, in addition, they were unexpectedly drawn into more
general district management meetings as well. This consumed the time of
the family physician with management tasks they were not intended to
perform:
‘What we didn’t anticipate was that once we put family
physicians on board everybody will call them into meetings’
Page 6 of 21
Conclusion
The appointment of family physicians in the DHS, who are trained within
the new speciality training programmes, is in the early stages of
development. They have impacted the DHS positively in terms of health
system performance and clinical processes. It is anticipated that this will
lead to a positive impact on health outcomes…The appointment and
development of family physicians is a work in progress. The functioning of
the DHS needs adjustment in some districts in order to better
accommodate family physicians and enable them to have the impact that
they are trained for.
Questions
1. How is the current District Health System Structured in Malawi?
How is it similar or different to what is described in the Western Cape of
South Africa?
2. Based on the reading, and on your clinical experience as a student,
have you seen opportunities where a family doctor could be helpful in
improving health care in Malawi?
3. The article discusses “unanticipated effects” of having doctors being
pulled into meetings. What are other possible challenges that will face a
family medicine consultant working in a Malawi District Hospital?
4. What are qualities of good leadership that the family doctors in this
article exhibit?
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions
Further Reading:
1) Scaling up Family Medicine in Uganda
Link: http://www.phcfm.org/index.php/phcfm/article/view/664
2) Family Medicine in an African Perspective – PowerPoint from Ghana
Link: http://www.mepinetwork.org/speakers-andpresentations/
item/download/40_f97c13550a705bb727a49383f9075d39
Comments from Further Reading:
____________________________________________________________
Guided Reading # 3: Palliative Care
Article: Quraishi N & Esler C. Metastatic spinal cord compression. BMJ
2011;342:d2402.
Link: http://www.bmj.com/content/bmj/342/bmj.d2402.full.pdf
Metastatic spinal cord compression is defined radiographically as an
epidural metastatic lesion causing true displacement of the spinal cord
from its normal position in the spinal canal. It is an important source of
morbidity (including paralysis and bowel and bladder disorders) in
patients with systemic cancer.
Page 7 of 21
Case scenario:
A 58 year old woman presents to her general practitioner with a two
month history of middle to low back pain. She has a history of breast
carcinoma, diagnosed eight years previously and which was treated with
a mastectomy and chemotherapy. She also describes pins and needles in
both legs for the past three days. On examination, she has tenderness
over the area of the T11 and T12 vertebrae and reduced power distally
(T4 and T5) but intact bowel and bladder function. She is referred
urgently to the metastatic cord compression coordinator, who organises
magnetic resonance imaging, which shows cord compression by a mass at
the T11 and T12 levels, thought to be caused by metastases.
How common is metastatic spinal cord compression?
 Skeletal system metastases are the third most common
metastases, after those of the pulmonary and hepatic systems2
 Within the skeletal system, the spinal column is the most
common site of metastases2
 Metastatic cord compression is estimated to occur in 5-10% of
patients with cancer (most commonly those with breast,
prostate, and lung cancers) and in about 40% of patients who
have pre-existing, non-spinal bone metastases.
 Symptomatic metastatic spinal disease is expected to become
more prevalent as survival rates for many common cancers
improve
Why is metastatic spinal cord compression missed?
Low back pain is one of the most common complaints in primary care,
with most cases being benign, self-limiting, and not needing a specific
diagnosis. The challenge in primary care is therefore to identify those
cases low back pain is caused by a serious spinal disease, such as
malignancy.
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions
Low back pain may be the first presentation of malignancy, and about
23% of patients with spinal metastases are thought to have had no
previous diagnosis of cancer.
In a prospective observational study of 319 patients with metastatic cord
compression, a median of two months passed from the onset of pain as
reported to their primary care providers until the diagnosis of metastatic
cord compression.5 Therefore, new onset back or neck pain in a patient
with known cancer must be considered to be spinal metastatic disease
until proved otherwise.
Why does it matter?
Although the rate of clinical progression is variable, patients with motor
dysfunction inevitably progress to complete paralysis in the absence of
intervention.6 Almost half of patients cannot walk by the time of
diagnosis.7 However, neurological status at the time of diagnosis,
particularly motor function, has been shown to correlate with prognosis
from metastatic cord compression,8 thus reinforcing the concept that
diagnosis before the development of a neurological deficit is of
paramount importance. Furthermore, treatment before paralysis is
clinically and cost effective.
How is it diagnosed?
Clinical features
All segments of the spine can be affected by metastatic cord compression,
but the thoracic spine is the most commonly affected site (about 70% of
cases), followed by the lumbar spine (20%), cervical spine, and sacrum.6
As thoracic pain is less common in the general population than pain
originating from the mobile cervical and lumbar regions, pain in the
thorax should increase suspicion of the likelihood of cancer.10
Page 8 of 21
Indeed pain is the most common presenting symptom of spinal
metastases, occurring in 83-95% of cases.7 Three classic pain syndromes
affect patients with spinal metastases: (a) local pain, with pain at rest
(resulting from periosteal stretching from tumour growth and/or local
inflammatory processes); (b) mechanical pain, with pain on movement
and improved by rest (owing to instability); and (c) radicular pain (owing
to irritation of a nerve root).7 Patients will often present with a
combination of these, and they may have both myelopathic (with long
tract signs such as upper motor neurone signs) and radicular
abnormalities. They may have lower extremity weakness and hyper-
reflexia below the level of compression (hyporeflexia if the cauda equina
is compressed).
Sensory changes such as paraesthesia or anaesthesia typically occur in
correlation with motor weakness. Patients may therefore complain of
sensory abnormalities in the same dermatomal distribution as their motor
dysfunction, and patients with myelopathy may describe a sensory
change across the chest or abdomen. Patients may also have some
degree of dysfunction of the bladder, bowel, and sexual organs as a result
of metastatic cord compression. Of these autonomic findings (present in
40- 64% of patients with metastatic cord compression),11 bladder
dysfunction is the most common and often correlates with the degree of
motor dysfunction. 10 Sensory and autonomic symptoms and signs
present late in these patients, and clinicians must therefore have a low
suspicion threshold if patients with known malignancy have back pain. In
the United Kingdom the guidelines from the National Institute for Health
and Clinical Excellence (NICE) recommend education of patients at risk of
developing metastatic spinal cord compression so that they know what
symptoms to look out for.12
A general practitioner who suspects a patient of having metastatic spinal
cord compression must immediately contact a specialist spine or
oncology team for consideration of urgent imaging and further
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions

management. The NICE guidelines recommend that centres treating Primary treatment depends on a patient’s performance status, prognosis,
patients with this condition have a coordinator who advises clinicians, preference, and tumour histological type. In very frail, terminally ill
coordinates care, and organises urgent magnetic resonance imaging (fig patients, active treatment may not be appropriate. Most patients are not
1⇓ and fig 2⇓).12 Such imaging remains the optimal imaging modality for suitable for surgery and should receive urgent external beam
assessing spinal metastatic disease (sensitivity 44-100%, specificity 90- radiotherapy, although systematic reviews give no clear consensus on the
93%).13 14 Figure1 best radiotherapy dose and fractionation.17 Patients with paraplegia are
unlikely to regain any function, and treatment is mainly intended to help
Fig 1 (to the Right) Is a T2 with pain.
weighted sagittal magnetic
resonance scan showing On the basis of a systematic review from the NICE guidelines of moderate
metastatic spinal cord to low quality evidence from retrospective studies,18 19 20 21 one
compression by a mass at prospective non-comparative study,22 one randomised controlled
T7-T8 (arrow) study,23 and an indirect comparative meta-analysis,24 surgery may
provide better patient outcomes (including pain relief, a better chance of
How is it managed? neurological recovery, and maintenance of ambulation) than
radiotherapy in carefully selected patients.12 NICE therefore
Metastatic spinal cord recommends surgery (decompression and stabilisation) plus radiotherapy
compression is an for patients who are fit enough for surgery, have a prognosis of at least
oncological emergency three months, and have:
and, once it has been
radiologically confirmed, - Spinal cord compression and have not had paraplegia for more
definitive treatment should than 48 hours, or
ideally start within 24 - An unstable spine, or
hours of diagnosis. Patients - Deteriorating neurological function, or
may have considerable pain and should receive analgesia in accordance - Pain despite previous radiotherapy.
with the World Health
Organization’s “pain ladder” Chemotherapy may occasionally be used as a primary treatment for
(http://who.int/cancer/palliative/painladder/en/). NICE guidelines metastatic cord compression that results from chemosensitive disease
showed, on the basis of a systematic review of low quality randomised such as small cell lung cancer and lymphomas. Whatever treatment a
controlled trials and observational studies, that corticosteroids patient receives, ongoing multidisciplinary care is crucial, attending to the
(dexamethasone 16 mg daily with gastric protection) may result in rapid patient’s medical, social, and psychological needs. Although rehabilitation
improvement of neurological function.12 15 16 is important for some patients, palliative care is crucial, as only about a

Page 9 of 21
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions

fifth of patients with metastatic cord compression will survive for more 3. Summarise the management options available for a patient who is
than one year.12 confirmed to have SCC

Key points
- New onset back or neck pain in a patient with known cancer must
be
- considered to be spinal metastatic disease until proved otherwise
- If metastatic cord compression is suspected, urgent specialist
referral 4. Briefly outline whether you think SCC should be correctly
- is critical as early diagnosis and treatment improves quality of life understood as a ‘palliative care emergency’?
and
- functional outcome, such as the prevention of paraplegia
- Magnetic resonance imaging is the optimal imaging modality for
- assessing spinal metastatic disease
- Initial treatment includes corticosteroid use, with urgent
definitive
- treatment comprising surgery or radiotherapy
Further reading:
1) The first two papers highlight how easy it is to miss this diagnosis even
Questions: in more well-resourced settings and contain interesting narratives from
1. After reading the paper summarise how a patient with SCC may patients, nurses and doctors.
present https://www.rcn.org.uk/__data/assets/pdf_file/0005/380858/2011_RCN
_research_3.6.1.pdf

2) http://www.ncbi.nlm.nih.gov/books/NBK55002/

3) Detailed overview. Some nice MRI pictures:

2. Which patients should you suspect may have SCC?
a. What systems would you need to examine?
http://www.acutemed.co.uk/docs/SCcompression,NeurolClinics,2-03.pdf
4) Older research outlining the value of high dose steroids (with radiation)
which can be useful in low resource settings.
http://onlinelibrary.wiley.com/doi/10.1002/ana.410080404/abstract;jses
sionid=FD9A7E9F17B6743A88BBBCAC7B877EA6.f02t01

Page 10 of 21
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions

Guided Reading # 4: Adolescent depression northern KwaZulu-Natal, first as the community doctor
and then as medical superintendent. In 1998, I was
fortunate to spend six months on “sabbatical” (a
euphemism for unpaid leave) at the Monash University
Centre for Rural Health in Victoria, Australia, after which I
returned to Manguzi for a further period. While in
Guided Reading # 5: Approaching burnout
Australia, I spent time reflecting on my life and work at
Manguzi and recharging my batteries. I realised that I had
Article: Ian Couper. Approaching Burnout. South African Family Practice.
been teetering on the brink of burnout (see box 1). This
Vol.47, Issue 2, 2005
led me to pursue the topic of stress and burnout in my
Link: (http://www-
reading. I found that much has been written on stress and
tandfonline.com/doi/abs/10.1080/20786204.2005.10873179)
burnout in doctors, but less on the early warning signs of
burnout. Since then, I have been involved in teaching
Introduction
undergraduate students and running workshops with
David Hilfiker wrote, “Like many practising physicians, I entered
doctors on the issue. I found that much has been written
medicine out of a desire to be of service to people. Whatever other
on stress and burnout in doctors, but less on the early
motives I may have had, my root ambition was to help, to respond to
warning signs of burnout. Since then, I have been involved in teaching
other’s needs. What I failed to realise,
undergraduate students and running workshops with doctors on the
however, was that the very nature of my
issue.
work as a doctor would push me
continually into the position of limiting
the help I would give, of ignoring the
The problem
needs of others. One of the pressing
One of our problems as doctors is that we often, unintentionally, see
realities of my job was that I repeatedly
ourselves as invulnerable. We believe most of the great myths of medical
found myself contradicting my own
practice: doctors do not get stressed, doctors do not get sick, doctors
inner desire to be of service, a conflict
should know everything, and uncertainty is a sign of weakness, as is
that created in me a deep sense of
revealing one’s emotions. We are uncomfortable with the concept of
guilt..... At the heart of this conflict lay
the wounded healer (see box 2). We may be vulnerable to a sudden
the simple fact that there were too
blow, like a myocardial infarct, the thought of which may preoccupy
many patient needs for the time and
us. The danger, though, is that we are more often at risk, without noticing
energy I had available”. 1
it, of being extinguished gradually, as our inner lives slowly dry up until
I spent seven years, until 1997,
we are empty shells, unable to function any more. That is the point that
working at Manguzi Hospital in
has been called burnout, a state of physical, emotional and mental

Page 11 of 21
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions
exhaustion caused by excessive and/or prolonged stress. It is often
related to unrealistic, high aspirations and expectations of oneself,
combined with impossible goals.
Why?
How, and why, do we get to this point? Although we are not unique in
having to face this problem, it is largely the helping professions in which
burnout occurs, professions in which we are constantly giving of
ourselves to other people, juggling them and ourselves. I believe this is
because of the difficulty of maintaining boundaries between our different
roles and responsibilities and allowing certain ones to dominate. We
have to juggle so many responsibilities – to our patients, our family,
our staff, our profession, ourselves – that it is hard not to drop a ball
sometimes. We live with a range of tensions that we have to juggle and
where the boundaries are often blurred. (See table below.)
In all of these tensions, we have to work to find the boundary lines,
because if we do not manage these tensions, we eventually burn out.
How and when that happens depends on our own individual resources,
our psychological make-up, and our inbuilt protective mechanisms. Why
do these tensions arise?
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Why do we push ourselves so much as doctors? McCue suggests four
reasons why doctors work so hard: 2
1. Peer pressure – we want to gain respect from colleagues; we want
their praise and admiration.
2. Fear of failure – if you put all your energy into your work, your efforts
will be above criticism and your failures can be attributed to misfortune,
rather than to you personally.
3. Fear of “success” – long hours and publicly visible fatigue justify our
economic prosperity; if we are somehow successful without working hard
for it, we fear we will be judged harshly.
4. Self-importance – we can achieve maximum ego gratification at work,
where we issue orders, make critical decisions and receive praise from
our patients, whereas at home we are no different from anyone else.
The need to be loved may be a major component of our drive to
overwork. Studies of the personalities of doctors have found that we
often have unresolved dependency needs and feelings of inferiority;
medicine offers the opportunity to respond to the needs of others
and, thereby, to develop a feeling of self-esteem and accomplishment. 3
Stress
There is no doubt that there are definite stressors arising from our
profession, such as heavy work loads, after-hours calls, fatigue, conflicts
between our work and personal lives, dealing with life and death
situations, financial pressures, the information explosion, the threat of
litigation, increasing medical technology, etc. Four job stressors in
particular have been noted to be predictive of poor mental wellbeing
in general practitioners: the demands of the job and the patient’s
expectations; interference with family life; constant interruptions at
work; and practice administration. 4 Stress has different effects on
different people: some manifest stress physically, in terms of illness, while
others manifest it in terms of emotional difficulty. Personality types are
important: some people can continue functioning for years while handling
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions
enormous amounts of stress, while others might cave in within a few
months. Stress results in a range of problems, such as depression and
other mental illnesses, suicide, alcoholism and drug abuse, physical
illness and social isolation.
Early warnings
What are the early warning signs of burnout? We can all absorb a certain
amount of stress and tension and, like an elastic band, regain our shape.
But the elastic band reaches a point where it becomes misshapen and will
never return to what it was before. We thus need to be able to recognise
that we are becoming too stressed, that we are in danger of stretching
ourselves too far. The following list of early warning signs is based on my
personal experience and on some of the literature on the subject.
1. Loss of meaning
Burnout is characterised by a loss of interest in work, so that a person
dreads getting up in the morning and having to face the day. I did not lose
my interest in my work, although I was no longer enjoying it as much, but,
more importantly, my sense of purpose was dulled and my direction
lacked its former clarity. Without a vision to give meaning to what we
do, it is not long before we cannot do it anymore.
Hilfiker describes this well: “When the physician finds he is not
taking the needed time for reflective meditation upon the meaning of his
job, when he finds he is using laboratory tests and X-ray studies instead
of in-depth interviews, when he is giving pills instead of counselling or
explanation, when he himself is not getting his needed sleep: at these
points the physician needs to ask himself whether the values of efficiency
and productivity have not in fact gained the upper hand, submerging
other important medical and human values”. 1
2. Lack of focus and decreased efficiency
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I found it increasingly difficult to focus on particular tasks, with the result
that my productivity diminished. I would often find myself sitting at
my desk, not focusing on anything in particular, or not remembering
what the patient I was seeing had actually presented with. I often did
minor, trivial tasks and tackled non-urgent, unimportant problems
because these were easy and I felt lacking in energy to deal with bigger
issues.
3. Depleted inner resources
I felt less able to deal with problems that arose with patients and
colleagues. It was a great drain to deal with these. I would just groan at
the thought of the hassle and felt depleted of the emotional energy to
tackle them. It was difficult to feel compassionate towards people in
need, because my own needs were starting to press on me too
strongly, even though I was not aware of them.
4. Irritability
I was irritable with many people in the work context, both patients and
colleagues. I found it difficult to remain patient and to be a good listener.
This is a step beyond merely not focusing and arises from the depletion
of inner resources.
5. Insecurity
Although I was in a position of leadership, as Medical Superintendent
of Manguzi Hospital, I found that I felt insecure in my leadership and that
I was vulnerable to criticism. This led to a preoccupation with what others
were thinking and wasted energy while I dealt with perceived slights and
attacks.
6. Mistakes
I made a number of mistakes through carelessness, inattention or lack
of focus on the problem at hand. As doctors we often make mistakes, but
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions
if we are making more than normal we need to ask ourselves why and
do something urgently to address the problem.
7. Lack of insight
At the time I failed to realise what was happening – it was only in
retrospect that I became aware of my lack of insight. Most people who
are burning out fail to identify the role they themselves play in the
condition, but instead blame others or their work environment, react
cynically towards suggestions or help, and often appear resentful,
fatigued, bored, edgy or withdrawn. 5 The American Psychological
Association describes this pre- burnout stage as “brownout”, listing the
successive stages of burnout as “The Honeymoon”, “The Awakening”,
“Brownout”, “Full- scale Burnout” and “The Phoenix Phenomenon” (if
one deals with the burnout well enough). 6
Dealing with burnout
To deal with these things, to try to cope with stress and prevent burnout,
we need to undergo a journey – a journey of change. Until we are ready
to move out of the roles others define for us and look at ourselves, define
our own roles, and decide the importance of them, we will remain stuck.
The first step in the journey is to recognise our own limitations, to
accept that we are not gods, but that we are fallible, vulnerable, needy
human beings who are wounded and alone, just as our patients are.
As Hilfiker puts it, “the first step is to allow ourselves to know we can’t do
it all. Recognising our own limitations, we can begin to tailor our work to
our own individual gifts. Second, we must recognise that we cannot
deal with the stresses of our work alone”. 1 We need the help of others.
Getting in touch with our limitations, journeying into our woundedness,
makes us better doctors, because we can share the results with our
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patients – we can empathise, we can understand, we become more
human. The problem, of course, is that this draws us into sharing more
of ourselves and thus being drained more! We have to deal with that
too: the wounded healer may be a good doctor; the sick, tired or
burnt-out doctor is NOT – for the reasons outlined above he cannot
function effectively.
Strategies
We thus need to develop strategies to avoid burnout. These are well-
described in the literature, but I will briefly mention the important ones.
1. Supportive people
Most importantly, we need other people to support us. We need close
friends, a partner or spouse, family, etc., who can draw us away from our
doctor role, laugh and cry with us, and help us not to take ourselves too
seriously. We need our own family doctor, whom we should visit regularly
to ensure that we are looking after our own physical needs. We need
to reflect and debrief – this can be done privately through journaling,
or with someone else, be it a friend or a professional counsellor, who can
help us reflect on a regular basis.
2. Physical self-care
Basic physical self-care obviously goes beyond just visiting a GP: we need
all the things we tell our patients to get: sleep, a good diet, alcohol in
moderation, exercise, sex and relaxation. This means we have to build in
time off and time away. We need to spend time cultivating our other
roles, whatever they may be: spouse, parent, friend, team member in a
sports club, actor in a dramatic society, birdwatcher, etc. Each of us will
have our own techniques. I jog, not because it is my favourite form of
exercise, but it is one that I can do anywhere and I can be away from
phones and demands. I am a passionate reader of thrillers because
they provide a way of escaping and giving my mind a chance to be
absorbed by unreal problems that are not my own. I also believe that
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions

time out to look objectively at what we have been doing and to reflect is
vital – that is what a sabbatical is all about.

3. Clarifying goals
We need to take time to reflect on our goals and our purpose, and to
ensure that what we are doing is in line with these. Sometimes, testing
the boundaries goes beyond learning how to deal with our tensions. Our
journey may take us to the point where we ask ourselves: am I trying
to put a shape into the wrong hole? Am I trying to squeeze myself into
something that is not me, something that will never fit? Sometimes
we use the hammer approach, which leads to self- destruction. The
constructive approach is to know myself, to see if I am really suited to
what I am doing, assessing the fit. This might be at the level of realising
that I do not fit the practice I am in, or it might be at the level of
saying that I have chosen the wrong career or even the wrong profession.
This is hard, but ultimately it is easier than destroying ourselves trying to Guided Reading # 6: Ethics in Family Medicine
fit something we are not. Sometimes it may just seem that it is all wrong,
and a break with some distance may be all that is needed to sort it out. Article excerpt from: Monsudi KF, Oladele TO et al. Medical ethics in Sub
Saharan Africa: closing the gaps.
Conclusion African health sciences Vol 15 Issue 2, June 2015
Ultimately, approaching burnout and dealing with it are about finding out
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4480461/
where I start and end, about knowing myself, and it is thus a spiritual
journey. Whatever our way of looking at the world, or our religious
framework, I believe it is vital to be connected to the spiritual side of [Review of four ethical principles - from the introduction section]
ourselves, as this is ultimately where our inner strength and resources are
drawn from. We ignore it or deny it at our peril. If we are to do this as Ethics is the application of values and moral rules to human activities.
successfully as we practise medicine, we must constantly remind Health care providers are expected to not only have the skills and
ourselves that self- care is not selfish. knowledge relevant to their field but also with the ethical and legal
expectations that arise out of the standard practices. Medical ethics has
been founded on the framework of four moral principles of autonomy,
beneficence, non-maleficence, and justice. The first of these principles,
autonomy, is the respect for the patient's right to self-governance, choice

Page 15 of 21
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions
in care, and the right to accept or refuse treatment. Beneficence is the
obligation to prevent or remove harm while also promoting good by
contributing to the welfare and acting in the best interest of the patient.
Non-maleficence implies the obligation of physicians not to inflict harm or
adverse effects on the patient from inappropriate or absent care (This
principle involves consideration of risks versus benefits from particular
procedures). The last ethical principle, justice means distributing benefits,
risks, and costs fairly, equitably, and appropriately, and treating patients
with similar cases in a similar manner.
Guided Reading # 7: Ethics in Family Medicine
Article excerpt from: Sippel D, Marchmann G et al. Clinical ethics in
Gabon: The Spectrum of Clinical ethical issues based on findings from in-
depth interviews at three public hospitals
PLOS One | July 10, 2015
http://dx.plos.org/10.1371/journal.pone.0132374
“[…] clinical ethics of everyday practice in the hospital setting has to be seen as a
distinct entity compared to research bioethics”
Introduction
For a long time, conceptual and empirical bioethics projects played only a
marginal role in Sub-Saharan Africa. As more clinical trials of HIV/AIDS drugs,
malaria treatments and vaccines started to be conducted in Africa, scholars in
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bioethics and health policy analysis began to study the ethical implications of
these clinical research projects, including informed consent issues, post-trial
access to trial drugs, and setting-relative risk-benefit analysis [1–4]. Capacity
building and infrastructure for research ethics and research oversight has been
improved in African countries and supported by various stakeholders. However,
clinical ethical issues arising in the doctor-patient relationship and in related
decision-making areas have received remarkably little attention and have not
been studied in a systematic and comprehensive manner. We argue that clinical
ethics of everyday practice in the hospital setting has to be seen as a distinct
entity compared to research bioethics because of observed and reported
differences we cover below.
The aim of this study was to analyze the spectrum of clinical ethical issues in
various health care settings in a Sub-Saharan country (Gabon) and determine the
factors leading to and influencing the issues that were reported. We therefore
chose a qualitative research approach, as this is the best mean to get insights
into the topic of clinical ethics in Gabon.
Materials and Methods
Hospitals included in this research project were 1) the Centre Hospitalier de
Libreville (CHL), the biggest and fairly well-equipped medical institution in Gabon
serving Libreville’s 619,000 [39] inhabitants, and patients from the rest of the
country, 2) the Hôpital Albert Schweitzer (HAS), a regional hospital located in the
up-country city of Lambaréné with limited technical equipment and 3) the
Hôpital Psychiatrique de Melen (HPM) just east of Libreville, which is the only
public psychiatric hospital in Gabon. These health care institutions are a good
representation of how health care is delivered to most of the people in Gabon.
For example, people from all over the country often take great efforts when
severely sick to get treated in the best-equipped public hospital, the CHL, as they
hope to get better treatment there according to interviewees. Furthermore, we
conducted interviews also at a rural hospital and at the only hospital for persons
with mental illnesses in the country. The private health care sector isn’t
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions
accessible to a majority of the people because of high prices and wasn’t included
in this study.
We interviewed 18 experienced medical professionals working in the following
areas: internal medicine, infectious diseases including HIV/AIDS, intensive care,
neonatology, pediatrics, gynecology and obstetrics, psychiatry, general
outpatient clinics, social assistance and nursing management. We used a semi-
structured interview guide that included open questions about the
understanding of clinical ethics, the ethical issues participants encounter in
clinical practice, the practical relevance of these issues, and how they deal with
them.
Results
Twelve main categories emerged describing issues that the interviewed health
care professionals of Gabon encountered in their practice and which they
classified as ethical issues. These could be grouped into three core categories
according to where the issues primarily arise: the micro, meso and macro level of
health care. All three levels are interdependent and therefore influence each
other. For example, the issue of who is informed about an illness was described
as being influenced by cultural and societal variables (macro level). But it is also
related to where and how staff members were educated regarding professional
communication and confidentiality (meso level). Finally, the physician decides at
the micro level (in a specific working environment) how to handle patient
information and confidentiality in relation to a specific patient.
Clinical ethical issues at the micro level
The micro level of health care comprises issues originating in the doctor—patient
relationship, the interactions of clinical staff and the self-understanding of these
individuals, as well as scarce resources of the patient, family and close friends.
Page 17 of 21
Confidentiality and disclosure of information
Several factors seem to influence the degree to which medical professionals
informed the patient and their relatives. After analysis of the data we could
recognize factors like the intellectual level, gender and psychological state of the
patient and relatives, the medical condition and prognosis, and who paid for the
treatment. We learned that the person who paid for the treatment often
received more thorough information, sometimes even more than the patient him
or herself, and at times without the patient’s consent. Concerning confidentiality
in the context of HIV/AIDS, we received different answers ranging from the staff
being “obliged to tell the husband” (if the partner was HIV positive), to being
“under oath” thus keeping confidentiality, or a “duty to persuade” the patient to
tell his or her partner.
Interpersonal, relational and behavioral issues
Several compliance issues were described as causing tension between the staff
and patients/relatives, including leaving the hospital against medical advice, drug
non-compliance, missing appointments, accusations and misbehavior arising
from specific types of undesired diagnoses. Some participants found it difficult to
accept that some patients were not interested in the disease and that some
relatives focused mainly on the costs of care.
Several interviewees highlighted the risk of subordinating patient care to non-
medical, secondary interests, or applying private convictions at work (e.g.
regarding abortion). The quality of communication between staff and patients
and their relatives was also criticized. Some physicians were said to work at
private clinics besides working at the public hospital. One participant complained
that physicians had their “business” running alongside. For her it was necessary
to “change the mentalities” regarding working morality to improve patient care.
Psychological strain of individuals
We found out that psychological strain not only resulted from issues of the
medical milieu in general (e.g. severe diagnosis, end of life decisions), but also
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions
from influences such as the lack of resources and mismanagement (see
respective passages).
Scarce resources
Interviewees reported that because of financial constraints on the
patient’s/relatives’ side, physicians sometimes could only “do the minimum” as
there were no means to buy drugs, perform medical tests, or to hospitalize a
patient with a severe illness. At times families were said to abandon patients
because of high costs, which resulted in considerable psychological strain for
everybody involved. While some saw the underlying problem in the lack of health
insurance, social security (see macro) and general poverty, others thought that
patients and their relatives also had a duty to contribute. Interestingly the
interviewed staff didn’t directly complain about their own financial situations.
Clinical ethical issues at the meso level
The meso level comprises issues with roots at the organizational and institutional
level, for example hospitals, schools, education and training of health care
personnel, as well as the family as institution.
Structural issues of medical institutions
According to participants clinical ethical issues were often related to a general
shortage of staff, especially of specialists (psychiatry, oncology, psychology, social
workers). We were told that relatives had to take charge of nursing, nutrition and
hygiene to complete the care package, which resulted in disadvantages for
abandoned patients or patients without a large caring family. Furthermore,
favoritism was described as playing a role in staff recruitment as well as in
whether patients got admitted or not. All of the above were said to contribute to
psychological strain on staff as well as on the patients and relatives.
Other ethical issues at the meso level included unequal access to health care,
especially in rural areas, for example HIV/AIDS information programs, outpatient
and rehabilitative care. Again, we learned that not all access to care issues were
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due to scarce resources. A major problem was seen in the inadequate
management of the institutions’ available resources. Corruption and
organizational incompetence resulted in inefficient utilization of already scarce
resources according to participants: “the technical level is probably not very
developed, but with the minimum that we have, we could do a lot of things.”
Issues with private clinics
While we didn’t interview the staff of private clinics, interviewees nonetheless
related some ethical issues to the role of private clinics. It was argued that
private clinics focused rather on “simple pathologies” and making money,
sending away more complicated patients with more expensive and complicated
conditions. These patients then had to be treated in a public hospital.
Issues related to the family
We considered patients’ families as social institutions and therefore placed these
issues at the meso level. Supportive relatives were reported to be very important
in case of serious illnesses, and high expectations were placed on the family, who
often had to put aside other duties or other family members at home to care for
the ill. We learned that this demand could “paralyze” the whole family. The
interviewed health care professionals described their difficulties engaging in
these complex interrelations and accepting families abandoning patients due to
scarce resources: “it’s true that people say the African family is big, but as soon
as you are sick for more than a week at the hospital, you might have no more
family”. Besides the duration and cost, other reasons for abandonment of
patients, that were mentioned, included the particular illness, especially in the
case of HIV/AIDS and psychiatric illnesses. Further, medical professionals
described moral distress when caring for orphaned children, as they often didn’t
get any official support despite the goodwill of health care professionals and
institutions.
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions
Issues of education, training, competence and skills of staff
Interviewees regarded education, training, competence and skills as key
elements for good health care and adequate conduct in ethically challenging
cases. A participant highlighted an often-experienced lack of self-criticism by
some staff members. She said that senior physicians mostly trained in France
during the 1960s–1980s when physicians had a rather paternalistic and self-
confident attitude towards their patients. After their specialization they would
come back to Gabon, practice and teach their students how they had learned.
Most participants said that they had not received any explicit ethics education,
either at medical school or from continuing education. One participant argued:
“Ethics is only perceived as a research term, that’s all they know, but before
arriving at research, there is ethics of everyday life”. However all participants said
that ethics and ethics education were important and should be improved.
Issues of education, training, competence and skills of patients/relatives
Education and competence were also considered to be important on the
patients’ and relatives’ side. Several participants told us about manifold issues in
this area. Uneducated patients and relatives also were said to cause conflicts as
the staff sometimes had to “submit” to the lesser educated.
Clinical ethical issues at the macro level
The macro level comprises issues arising in the cultural, sociological, religious,
economic and political context.
Influence of society, culture, religion and superstition
Interviewees reported that traditionally the family plays a central role in
Gabonese society, which influenced how they informed the relatives, as they
thought the family had a right to know what was going on. However, it was also
described that this has been changing as the development into a more
individualistic society could be seen. Interviewed health care practitioners faced
dilemmas in situations where it was unclear to them whether to inform patients
and relatives in the traditional way or not.
Page 19 of 21
Old convictions still seemed to play an important role. One participant even said
that they were “imprisoned in the tradition” as to how illnesses were perceived
and treated. HIV/AIDS, cancer and mental disorders were still commonly seen as
“mystical illnesses” by patients but also by health workers, as even some staff
members described psychiatric illnesses as “mystical”. “Mystical illnesses”
appeared as a punishment for wrongdoing to some. One example that was given
is that one contracts HIV and its secondary diseases “because you did something
wrong [in life]”. In consequence we learned that patients with “mystical
illnesses”, as well as women who undergo illegal and disrespected abortions,
risked stigmatization, abandonment and that these patients would often have a
hard time to reintegrate into society once they recovered. These “mystical”
beliefs must be seen as part of the local context and tradition. In many African
traditional religions the concepts of spirits, ancestral spirits and spirit possession
play an important role and are still very present today. Sometimes these belief
systems lead to clinical ethical issues as in the case of psychiatric illnesses that
are often regarded as “mystical”. Health care professionals face ethical dilemmas
in how to respond to these convictions.
One participant proposed that clinical ethics was a problem of “rich countries”
and that there were more important issues to deal with before considering ethics
more explicitly in medical training and continuing education. An example of a
more pressing issue by this participant was the bad condition of medical
equipment and the low level of advanced medical technology in Gabon. However
several participants strongly disagreed and saw it as a very important topic that
needed to be addressed in parallel.
Applicability of western medicine
A physician suggested that western diagnostics and therapy guidelines weren’t
applicable in Gabon because of a different population (majority of people with
African origin vs. mostly Caucasian subjects in most clinical trials) and also a lack
of resources (officially recommended treatment options often not available)
leaving her without evidence-based treatment options. Because of resource
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions
limitations she said that she needed to pursue a “mass policy” for her patients
rather than an “individual policy”, not doing justice to every patient.
Structural issues at the political level
The health care institutions were described as being “politicized”, meaning highly
influenced by politics. Interviewees saw this in a lack of continuity, with
administrators who said to often be swapped for political reasons. Health care
professionals at lower organizational levels reported it to be difficult to “change”
anything.
Legal issues
We heard about a “judicial vacuum” that led to medical ethical issues. One
example given was the handling of needle stick injuries and the lack of
compensation for work injuries in general. Also the unclear judicial situation over
the detention of psychiatric patients was seen as an issue, as it was reportedly
relatively easy to lock someone up without legal restrictions, which gave a lot of
power to psychiatrists.
Discussion and Conclusion
This qualitative analysis of 18 in-depth interviews presents the qualitative
spectrum of clinical ethical issues currently encountered by physicians, nurses,
midwives, and social workers in different public health care environments in
Gabon.
In most physician codices ethical issues refer to the ethical theory of principlism
[44,45]. In the original theory for medical ethics principlism is based on the four
basic principles of non-maleficence, beneficence, respect for autonomy, and
justice. In the ethical theory of principlism these basic principles represent prima
facie binding moral norms that one needs to obey unless they conflict with an
equal or greater obligation in a particular case. When this approach is applied,
the principles have to be specified and balanced against one another if a conflict
arises. With respect to the principlism approach, an ethical issue in clinical
Page 20 of 21
practice might arise (a) because of the inadequate consideration of one or more
of these ethical principles (for example: insufficient consideration of patient
preferences in health care decisions) or (b) because of conflicts between two or
more of the mentioned basic ethical principles (for example: balancing the
principles of patient autonomy, non-maleficence and justice in a case where a
HIV positive patient won’t tell the spouse of the sero-positivity potentially
harming the partner).
Our findings demonstrate that scarce financial and human resources cause and
influence clinical ethical issues in different ways and on interdependent levels of
the health care system. However, the findings also show that clinical ethical
issues in Gabon—and most probably also in other developing countries—cannot
be reduced to problems of limited (financial) resources alone. The specific
cultural, societal, and religious contexts give rise to specific clinical ethical issues
such as confidentiality issues, challenging roles of relatives in medical decision-
making, and the appropriate attitudes of health care professionals towards their
patients. A striking example given above is the understanding of confidentiality
within the family context playing a more important role than in contemporary
“western culture”. This leads to an understanding of confidentiality that makes it
“normal” for at least some health care professionals to share information with
close relatives even without the permission of the patient. While many of these
clinical ethical issues are well known and broadly discussed in the international
bioethics literature [44,52,53], it is still unclear to what degree existing ethics
guidelines [54], clinical ethics consultation models [55] and medical
professionalism frameworks [45] (mostly produced by health care and bioethics
institutions in an Anglo-American and Western European environment) can be
transferred to and successfully implemented in African countries that face similar
but differently shaped and contextualized ethical issues. We found many clinical
ethical issues (see Fig 1 and additional supporting information S1 File) that
seemed particular to the specific Sub-Saharan African cultural background and
the professional self-understanding of the medical staff working in this
environment. Furthermore, the understanding and conviction of how far
University of Malawi College of Medicine – Academic Year 2017-2018 - MBBS 4 Family Medicine Rotation - Guided Reading & Questions

physician confidentiality and other elements of medical professionalism should

reach clearly varied among the participants. At the time of the study there
existed no official Gabonese code of medical ethics or professional ethics for
health care professionals in Gabon that would give an official framework for this
[56].
In summary, the spectrum of clinical ethical issues encountered by health care
professionals in Gabon, the dependence of ethical issues on cultural and social as
well as financial aspects, and the varying attitudes of health care professionals
towards ethical issues and different understandings thereof call for a more
explicit discussion of and further research into clinical ethical issues in low-
income countries.
Questions
4. If a similar study was conducted in Malawi, do you think the findings would be
similar or different? Please explain.
Further reading
(1) Daniel K Sokos: How to think like an ethicist. BMJ 26 June 2010; Volume 340;
Page 1389 http://www.bmj.com/content/340/bmj.c3256.long
(2) Kavinya T: Do you think doctors are practising compassionate medical
ethics? Malawi Medical Journal 2008 June 20(2): 71
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3345664/

In this paper, we learn about ethical issues in clinical practice as experienced by
health workers in Gabon in West Africa.
1. Have you encountered any of the ethical dilemmas described in this paper?
Please explain.
(3a) Papanikitas A and Toon P: Last but not least: the ethics of the ordinary.
British Journal of General Practice 2010 Nov 1 60(580): 863-864
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2965985/
(3b) Cyril A, Al Atroshi L et al: Ethics of the ordinary: a class response. British
Journal of General Practice 2012 Feb; 62(595): e143-e146
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3268494/#b3/

2. Did any of the ethical dilemmas described surprise you? In what way?

3. From the ethical dilemmas described, can you find examples that illustrate the
four pillars of autonomy, beneficence, non-maleficence and justice? Please
choose one of the pillars and describe.

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