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FIVE LESSONS AT FIVE (PART 5)

Sometimes back I was invited by my alma matter to the annual convocation cum freshman dinner. While thinking on what remarks to make, I thought of reflecting on the first five years as a consultant and what life lessons I have learnt that may resonate with a new consultant setting out for work. That speech did not happen, so my thoughts remained as thoughts. In a month or less, I got into a conversation with former schoolmates on the sidelines of a scientific conference. One of the stand out observations was how time was flying since we have been out of training. 

‘ I cannot believe it has been five years!’, I said. 

‘I cannot believe it is already 10!’, another observed. 

I got back from that conversation wondering, what are the lessons I have learned on the surgical streets during those 5 years? 

I christen them five lessons at five, what young consultants would love to hear as they hit the ground running.

5. APPRECIATE THE POWER OF A DOCTOR’S SIGNATURE

It was on a Tuesday February night and we had gathered in a Hotel in Nairobi’s Village Market. 

One of the guest speakers at the dinner was our new Hospital CEO. 

When he rose to speak, he did not bother to waxy lyrical in gargantuan academic lingua. He opted for the basic common sense appeal to us. The room was full of doctors. Young trainees enthusiastic to start off their training program, mid level residents getting comfortable with the their lines of professional specialization, senior residents who could not wait to finish and hit the market as specialists, and of course the professors and senior consultants who had been at this trade for eons. 

The CEO addressed himself to one thesis. That the hospital was exceedingly finding itself expensive. That this was a weakness to address. That the entire file and rank of people to bring down that cost was in the audience, listening and looking at him. 

He reminded us of the power of a doctor’s signature. That nobody would question a doctor whether they prescribed a 500 shilling worth of antibiotic or a 5000 shilling one. 

We were the only ones who could question ourselves before appending that signature for the expensive drug, the sophisticated lab test, the fancy scan. 

“Doesn’t affect me” I told myself. 

It is a discussion we had had on many of our academic  and mortality meetings. 

“Even if the patient has insurance, that money eventually comes from somewhere. Try as much to save it,” one faculty always insisted. 

Because of that, it was not unusual for us to critique each other’s management from an economic angle, when the scientific and practical angles were covered. 

The import of the CEO’s concerns dawned on me a few months later. My colleague was in the surgical clinic. As usual, to survive the residency, we used to debrief in the evening- talk about our experiences for the day. He narrated to me how he had hidden MRI scans of a patient from the professor. The patient had been sent in by a general practitioner for surgeon’s review. He suffered from a ganglion cyst (a small harmless collection of fluid on the back of his wrist joint). A ganglion cyst needs a minute to look, touch and make a diagnosis. It does not need a scan. Just a trained pair of surgical eyes. But the patient carried an A3 envelope containing MRI films. He had had a scan worth 20,000 shillings to make a diagnosis that just needed a cursory look and touch from my colleague. 

“I knew if Prof saw the MRI he would get a seizure”, my colleague pronounced amid bouts of laughter. 

A doctor’s signature had sanctioned a scan that was possibly avoidable. 

It is not doubt that a doctor’s signature is mighty. It can veto a presidential decree and mitigate a supreme judge’s verdict. 

Equally, the doctor’s signature can be utilized for the vital obligation of advocacy for the patient. Often I have found myself advocating for the patient to their insurers. 

It is common practice for insurance firms to require imaging scans as evidence of the indicated diagnosis before approving the requested surgery. 

But owing to the philosophy I have already fronted, why spend more money with the goal of curbing against loss of money? The insurance firms will argue that they are trying to curb insurance fraud. This is understandable. But so what? 

Why order an ultrasound of the groin when the republic has spent years and millions of shillings to train the workforce that should minimize the cost of healthcare to the population? 

I cannot tell you how many cases, I have had to argue, re-write medical reports or answer phone calls on this. 

‘No image provided!’ the rejection report will read. 

‘Clinical diagnosis made, no need for imaging!’ I will counter in my second report. Eventually, most patients will succumb to pressure and pay that 2,000 for the ultrasound or 1000 for the x ray just to be done with the process and prepare for the surgery. 

That is okay with me. Once in tens of cases, my statement will suffice and the surgery will be approved. That one case will keep me moving, my pen signing more and more ‘no need for imaging’ until the next one. 

Pirelli advert has it aptly- Power is Nothing Without Control. 

A doctor’s signature is powerful. But just like power, the signature must be used with responsibility and with restraint. It must be used without fear or favor. Especially to advocate for the needy in our society. 

About the Author

Dr. Stanley Aruyaru

Dr. Aruyaru is a Consultant General and Laparoscopic Surgeon and a Healthcare Manager. He has solid experience in managing busy surgical units and leading clinical teams to deliver in the lines of quality health provision and evidence based surgical practice.

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Expect nothing, live frugally on surprise. - Alice Walker

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