CHAPTER 2:LITERATURE REVIEW
2.4 Challenges in the Public Health Sector
2.4.6 Role of the Doctor
The doctor plays an important role in the delivery of health care as he/she is responsible for making a diagnosis based on clinical knowledge and the symptomatic presentation of the patient.
However, studies show that patients are concerned with more than just a good or accurate diagnosis from the doctor thereby highlighting various aspects that affect the doctor patient interaction or experience (Devanny,2015:25). The relative importance of compassion, communication and referrals may differ especially where the radiance effects of these factors are concerned.
• Compassion
According to Devanny (2015:26) when patients seek counsel from their doctors, it is usually during a stressful point in their lives. Patients want to know that they can trust their doctors with the responsibility of keeping them informed and empowered. In addition to clinical soundness from the doctor they expect the doctor to be caring and compassionate during their time of need.
Regardless of the health outcome, patients need doctors that provide care with compassion.
• Communication
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According to Levinson, Lesser and Epstein (2010:1311) the role of communication is strongly associated with the effectiveness of the doctor. Earlier research (Arora,2003:791; Epstein and Street,2007:805) shows the importance of communication towards supporting important outcomes such as the adherence to treatment plans and better self-management. An added benefit as noted by Robinson, McCallister, Berry and Dearing (2008:602) and Janglang, Gunningberg, and Carlsson (2009:200) is that communication influences the experience of care Inappropriate communication between professionals and patients can result in poor patient experiences (Nadzam,2009:186). When doctors are unable to communicate effectively, it has a negative influence on the doctor-patient relationship thus contributing to a negative patient experience.
The invaluable art of communication and the importance of sound discussion between patients and doctors are clear.
However, good communication should focus on identifying patient needs and improving shared decision making rather than seeking to solely addressing patient concerns. In addition to effective communication between the doctor and the patient, non-verbal cues are also deemed relevant to the patient experience as revealed in studies conducted in developed countries. Based on the study conducted by Devanny (2015:24) more than half of United States (US) and United Kingdom (UK) patients (68%) expect eye contact, a handshake and good verbal communication when consulting with the doctor. The patients in the study were of the viewpoint that these factors contribute the most to an overall positive experience.
• Consultation and Confidentiality
In Germany, privacy during the consultation was most significant to the patient and this was followed by communication, and eye contact. Poor compliance to patient confidentiality on the part of the health professional may influence the patient's ability to provide an honest account of their health needs. Patients expect confidentiality and doctors that listen when they talk (Devanny,2015:30). Whilst the emphasis has shifted towards reducing waiting times and improving productivity, the primary goal should always be to develop a strong bond between the patient and the doctor.
Experienced doctors often say: “it’s not the amount of time that is actually spent on the patient, but rather, it’s the perception of time spent that matters most to patients” (Levinson et al., 2010:1315). For example, when the doctor remains near the door during the consultation, the
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patient may feel rushed from a psychological perspective, but when a doctor sits near the patient, maintaining eye contact, and shows a willingness to know more from the patient, the visit appears longer.
• Referrals
The sense of being rushed not only negatively impacts patient experience but, it can create the impression that the patient is not priority and influences whether a positive recommendation will be made for the doctor. In Devanny's study more than half of the German patients (68 percent) use a family or friend’s recommendation when choosing potential doctors. Similarly patients in the US (52%), and UK (24%) agree that their choice of a health worker is influenced by a past experience of a friend or family member (Devanny,2015:34). Whilst the percentage of patients showing agreement in the UK is considered to be much lower than that of German and American patients, it is clear that this is an important point for patients. Therefore the role of the doctor-patient relationship does not only influence the experience of the patient that is in the doctor’s room’s but also impacts on future potential patients. If the patient in the consulting room has had a negative patient experience, then it is possible that they will be less inclined to recommend the doctor of note to a friend or family member. Based on the statistics provided in Devanny's study this could hold negative implications for the doctor who has elicited a poor or negative patient experience.
• Availability of Skilled Doctors
Longmore and Ronnie (2014:369) evaluated the insufficiency of human resources in healthcare (HRH). It is evident that the supply and demand balance of current and future doctors are ineffective which translates to human resource constraints within the public health sector in SA.
Although the government has recognised that human resource constraints affect the overall functioning of the health system and provision for this constraint has been accounted for in 10- point strategy plan (DoH,2016:33) there is a concern that the efforts are misguided and inadequate to cater to the issues timeously (Longmore and Ronnie, 2014:369).
Only 30 percent of health professionals in SA work in the public domain in spite of the high volumes of patients that frequent public centres (80%) (DoH,2016:24). There is less than 1 doctor for every thousand people, compared with an average of more than three doctors in
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developed countries (Jackson,2015:3). Even further, less than five percent of medical students who graduate willingly proceed towards rural areas (Robinson,2015:11). A further issue facing SA and other low and middle income countries is "brain drain". The issue of "brain drain" has been brought to the attention of platforms such as the WHO and also through the negotiation of bi-laterals with developed countries. Government statistics indicate that there is a vacancy total of 10 860 for doctors (DoH,2016:30). Many of these posts have been frozen due to meagre financial resources, yet the government has been ineffective in its effort to address the problem.
To compound the issue of the shortage of health workers, the Health Professions Council of South Africa (HPCSA) increased the requirements for foreign trained professionals to serve as independent practitioners in SA (Health Professionals Council South Africa (HPCSA,2016:4).
Another challenge as highlighted by the DoH (2015:5) is that of the role of HIV which has affected the health worker population and impacted patient workloads. Occupational health hazards are increasing in health facilities. Tuberculosis among SA health workers is rising.
Health workers have a higher exposure to contagious diseases and when they are affected, it affects their ability to work because the roles are now reversed. The consequences of inadequate staffing have important implications for the patient. One of these being that the patient may be required to wait longer before they are attended to. In addition, by the time that the patients have been attended to, there is every possibility that the health worker may be so fatigued by the extra work load that their judgement could be impaired.
This type of scenario could only lead to potential malpractice and patient negligence. In particular, doctors that are over-worked are unable to communicate effectively and will not be able to offer the type of service that patients should receive. Doctors will want to work quickly just so that the workload can be completed and this may encourage verbal and non-verbal cues that are not reflective of empathy or compassion for the patient. Simply stated the situation where there are insufficient doctors could potentially elicit a negative patient experience.
The response of the DoH by 2018/19 is to possess suitably trained healthcare staff that possesses the required capabilities will deliver quality health care. If this is achieved, it will mean that the following positive health reforms will be achieved:
• " No patient goes home unattended due to a lack of staff;
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• No employee feels that going the extra mile is not worthwhile;
• All workers are engaged and ready to perform at their best; and
• No clinical professional is overburdened with administrative tasks" (DoH,2016:41).
These aspirations seem noble at first glance but one has to wonder whether it is achievable for the short and long run.