What the Smart Principles Can Teach Physicians about the Responsible Treatment of Patients

> Posted by Josh Goldstein
The Smart Campaign’s Client Protection Principles are all about insuring that microfinance institutions (MFIs) put their clients’ interests first. Therefore, product offerings must be designed to be understandable, pricing transparent, the dangers of over indebtedness made explicit. The loan officer must be incentivized to ensure that her customer truly understands the terms of the contract being entered into. In short, the client must be equipped to make a fully informed decision. But this is easier said than done, as the Campaign well knows.
But microfinance is not the only domain where these challenges occur. I recently co-authored a paper with a team of physicians and other healthcare professionals: “Best practice guidelines on surgical response in disasters and humanitarian emergencies: report of the 2011 Humanitarian Action Summit working group on surgical issues within the humanitarian space.”
It was matter of serendipity (and to me some amusement and trepidation) that I ended up in a working group of surgeons, anesthesiologists and rehab specialists at this summit held at Harvard, and I was nearly certain that I could add no value– as our discussions were to largely focus on medical questions involving amputation.

When a highly trained surgical team flies into a conflict zone or a natural disaster area to set up an operating theatre, they often have little understanding of the local culture. This was certainly true of Haiti after the earthquake, which served as reference point since many in our group had served there. This is completely understandable. The call to action leaves little time to do anything but pack. And once on the ground in a strange country, in crisis circumstances, surgical teams are necessarily preoccupied with making an often jerrybuilt operating theatre as safe and user friendly as possible. Undoubtedly conditions will fall short. The electrical supply may be intermittent; water may be in short supply; there may be IVS but a shortage of sterile solution to fill them. Is it any wonder then that obtaining truly informed consent from patients ends up as low priority or may not even make the pre-op check list? Our group quickly agreed that this was probably an all too common occurrence in humanitarian emergencies but was unacceptable and had to be addressed in our paper.
If my role on this group was Ill defined in the beginning, it now came into focus. I pushed the group to determine what kind of protocol was necessary to assure that a patient was truly informed before being wheeled into surgery. This is where my being steeped in Smart Campaign principles helped the group’s deliberative process. Whether talking about a poor client or patient, many of the same issues come to the fore. The need for transparency is self evident when discussing with a patient and his family the pros and cons of limb amputation— but obtaining “informed consent” from an illiterate, scared patient is fraught with difficulty—heightened  by the fact that a decision  to amputate must for medical reasons made without delay. As our report emphasized: “…it is essential that patient and {his} caregiver understand the rationale for performing amputation… Consent documents should be clear and easily interpreted, made available in Braille for the sightless and supplemented with simple illustrations for the illiterate and in order to facilitate communication across language barriers.” Facing surgery is terrifying for anyone—and even when the surgeon is perfectly clear, a scared patient may not in his panic comprehend the true meaning of what is being said to him—which can be as true for a wealthy patient at an upscale hospital in Boston, as in Port-au-Prince.
Furthermore, the report continues, informed consent involves more than permission to do the surgery itself. It must include information about the risks facing a new amputee after discharge. In some cases, It is critically important for a patient with the newly fitted prosthetic device to return to the hospital some days after the surgery to make sure the artificial limb doesn’t need further adjustment and that no infection has occurred and that pain is properly controlled. Yet “….participation in the prescribed course of rehabilitative care was not possible for many patients who relied on families or caregivers that were pre-occupied with the daily struggle for survival; others had lost families and homes and did not have reliable access to transportation.” Surgeons must be made aware of, and take into account, these social factors before making the decision to operate.
As the report concludes, “the responsible humanitarian surgeon…must be mindful of what lies beyond the operating theatre for each patient: a lifelong battle with pain control, functional recovery and psychosocial reintegration.” Perhaps even more than when financial well-being is at stake, when medical decisions must be taken, successful and ethical outcomes will be more likely if truly informed consent is obtained.

Image credit: aafp.org

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