Trust is a fundamental element in interpersonal relationships and the importance of trust within healthcare cannot be stressed upon enough. Patients present themselves to healthcare providers at their most vulnerable time and must be able to trust both the institution and the individuals involved in their care. They must be able to trust that these individuals and organizations are competent and have their best interests at heart. At present this is far from true in this country. Most patients do not trust the institutions nor the individuals providing the care. They are weary and suspicious of any medical encounter. Numerous accounts of mismanagement, maltreatment and neglect by doctors are exchanged daily in the queues at IGMH or ADK. People would rather go abroad for the simplest ailment than get a consultation here at home.
Several factors have contributed to the buildup of this mistrust.
Firstly, as the face of healthcare, some doctors do not bother or are not trained in creating a healthy doctor-patient relationship that is crucial to the success of any treatment. Most Maldivian doctors are trained in South Asia, either in India, Nepal, Pakistan or Bangladesh, where a paternalistic approach to patient care is acceptable, practiced and used in training. The doctors know what is best and the patient should do whatever the doctors order, no questions asked. Procedures can be done on patients even without consent. There is no room for the patient to refuse treatment. On daily rounds it is common to see doctors scolding patients for not complying with treatment. The rights of the patient and proper ethical conduct are hardly an issue. Thus it is not surprising that such incidents are all too common in our hospitals where the doctors are either trained in or are from such countries. The possibility of trust in such an environment is impossible, especially when Maldivian patients in general ask more questions and are somewhat more aware of their rights (hence the popular belief among doctors that Maldivian patients are 'troublesome' and ʻdifficultʼ).
Secondly, healthcare institutions and individuals do not protect the patients' rights of confidentiality and treat their medical information as coffee-time gossip. It is all too common to hear doctors discussing personal details of their patients for their amusement, or lab technicians discussing a patient's paternity test. Healthcare professionals owe a duty not to disclose information against the patient's wishes as medical confidentiality is an important feature of the doctor-patient relationship.
Thirdly, healthcare institutions are all too keen to cover up medical mistakes and no framework exists to deal with such mistakes. Hardly any incident is thoroughly investigated and proper actions taken, and those wronged are not compensated. There are no professionals trained in legal medicine and those sitting on the ethics committee lack any training in the area.
Fourthly, there is no institution to regulate and standardize healthcare. The recruitment of expatriate doctors, who make up majority of doctors especially in the atolls, should be more stringent and registration at the Maldivian Medical Council should be followed by a licensing exam. Many are familiar with the account of a cook who used to work in one of the islands as a doctor for several years. There is a lack of standardized management protocols for common conditions, and adherence to those existing protocols is limited and not enforceable. There is no code of ethics or a code of professional conduct for doctors, which is a necessary tool for the regulation of the profession. Policy makers should consult healthcare professionals in making decisions that affect the health of the population in general. The recent changes to the appointment system at IGMH (which has fortunately been reversed), seriously violated a patient's basic right to choose his/her healthcare provider, and only intensified the public's mistrust.
In such a setting, where healthcare is not standardized or regulated, and where the healthcare providers are not bound by any obligations, legal, professional or otherwise, the public's mistrust towards healthcare is not surprising. It has increased the number of second opinions being sought and requests for referral abroad. Failure to comply with treatment is commonplace. It has also increased the number of people turning towards other sources of treatment.
Having said all this, I know of no doctor who wishes harm on his patient. Perhaps it is the combination of several factors rather than a single one that has led to this mistrust. Trust is a potentially powerful variable affecting healthcare decisions. And as such, both healthcare institutions and individuals should work to regain and reestablish this trust, by building a relationship in which the values and goals of both parties are clearer to each other, one of shared decision making, and one which promises to increase patient satisfaction and lead to greater understanding of treatment and illness.
[Contributed by Dr. Faisal Saeed]