For a few weeks I was placed at an outpatient setup as part of my clinical rotations. My first impression of the placement was a mixed one. Upon entering the clinic setting I was oddly amused at the structure to which patients are controlled upon entering the clinic. Patients are required to be at the gate an hour before their scheduled appointment and would not be allowed into the clinic after their appointment or if they do not have an appointment. Fair enough it assists the long stress of admin but in the same breath it causes more delays because now the collection of files becomes another wait and patients in any case pitch up late for their scheduled appointments. With two of the surrounding clinics being closed down this increased the number of patients needing to be seen and if a patient pitches up late the chances of them getting another appointment soon enough are slim to none. Anyway after that encounter the other side to this was the very warm welcoming from the head Physiotherapist as well as the other rehabilitation members.
During the first day I noticed that most of our patients have been scheduled and there was hardly any space for us to write follow-ups before supervision session or even make our own new appointments early enough. This was amplified by the very problematic approach of our rehabilitation receptionist who deals with the rehab diaries, making patient bookings on our behalf’s. Fair enough this accounts for days when we are not working or present then the system favours us. However, there was no communication with regards to which would be best fitted dates for new patients because all the spaces were occupied by new appointments made on our behalf even though the receptionist was made aware of allocated areas for new bookings because this influences and affects our learning experience as this was a treatment rotation.
A few weeks after this probably around the second or third, I had one of my patients pitch up who was scheduled for the previous day, but because of sudden death in the family, the patient was unable to attend. The patient first went to the receptionist before heading to the physiotherapy room for her appointment enquiry and the receptionist came to me with the patient details making a patient decision that I should see this patient quickly as she has been seen twice already and then I can just discharge her.
I was completely shaken by this response because first of all how can someone with no physiotherapy competency decide whether or not this patient should be discharged. Secondly this would have been the first time that I would be assessing and treating this patient hence I had no idea what the patient needed physio for. So in final understanding, my responsibility towards this patient was jeopardized by an administrative agent and if anything had to happen to this patient I would be held responsible because I had a sense of accountability not just to the placement but to my patient firstly. The whole idea that the receptionist thought that it was okay for him to decide on this disturbed me a lot and made me feel that everything was just about getting patients out of there no matter what the condition was. Yes I understand the influx of patients had increased with clinics closing down but my first responsibility was towards my patient. Who in the end after my assessment had low back pain accompanied by neurological symptoms, poor gait re-education and bilateral knee pain.
Anyway I felt too upset to accept this, I walked up to him and made him aware of my responsibility towards my patient and as a physiotherapy student I have more expertise to make an informed decision about this patients care. I also made him aware that this was my patient and if will gladly see her today as I had an opening. I reported my concern to the physiotherapist to make her aware of the pressures I was faced with and how it affects my learning, decision making and most importantly, my patients quality of care. All he kept telling me that day was that we only have one physiotherapist because the comm-serve left. Yes I am aware of that, but the physiotherapist would not be alone all the time, because every day except Fridays there were students present. This was not the first time a lack of patient focus was portrayed. In the latter days of this incident I had another lady pitch up almost an hour late for our appointment and the next scheduled patients were already there. The lady was held up at the gate and then the collection area. I informed the lady that the next appointments were far away from today because almost all my patients had pitched that day I was not sure if I would be able to see her. The lady became rather frustrated and emotional because she had made mention to me in tears how she has been trying so long to get an appointment for her daughter and her staying out of work affects her income and their basic needs. Now here again, had the receptionist acknowledged the spaces left open by note from the physiotherapist not to book in certain areas a next appointment would not have been too far away.
This called for a concern for patient advocacy. Do we as health professionals still advocate for our patients or are we too entrapped by the administrative duties? This whole display of lack of advocacy and agents who control the systems we are governed by is a concern. Agents are identified as those who intentionally influence ones functioning and life circumstances (Bandura, 2006), hence from the clinic gate right up to the diary booking, we are controlled within our learning experience and power of autonomy. These structures almost make decisions on our behalf because ultimately we have a sense of accountability to them. The question then is asked, “what has happened to our basic principles of ethics?”. As a recall, two of the most common principles are; beneficence and non-maleficence.
Beneficence means to do good. Caring can be defined as a principle of beneficence i.e a moral requirement to promote well-being, which in term implies, respect for autonomy and professional standards of due care for patients. It is important for therapists to always act in the best interests of their patients and society. Common examples are when therapists make decisions that are not guided by asking what is best for the patient, but by using other criteria that benefit either the therapist themselves, the institution or other patients.(As illustrated above) (Beauchamp & Childress, 2013) Non-maleficence means to do no harm. This principle affirms the need for medical competence. While it is clear that medical mistakes may occur, this principle articulates a fundamental commitment on the part of health care professionals to protect their patients from harm. (Beauchamp & Childress, 2013)
These basic principles are not standing in isolation as these are influenced and impacted by other components such as; power and control along with autonomy. The whole situation revolves around power, agency and control. The very agents that govern the systems that control us ultimately uses or abuses this power to control and govern our thinking, behaviour and influences our decisions. The broader aspect of ethics principles highlights the infiltrated influence of these agents in our decision making and within our ethical approaches. The ethics principles are often overruled by the abuse of this power or control of these systems which many of times silences our voices from advocating for our patients and leaving us abdicated from practising our autonomy as professionals in the making.
To bring this more standing ground, if we have a look at the SASP (South African Society of Physiotherapy) code of conduct under section 2.2 In terms of their commitment to appropriate patient/client relations – physiotherapists should ensure that patient management is not influenced by undue pressure from third party and section 5.2 In terms of their commitment to the profession – physiotherapists should Ensure that they maintain their professional independence and integrity when entering into any contract regarding professional services; recognise that they remain personally responsible to their patients for health care; and ensure that the terms and conditions of contracts entered into are fair. These basics rights and responsibilities were directly violated by these agents of power and control.
In future despite the setting or systems I have been made aware that these grounds are my validations and that I should be more assertive in practicing my autonomy with regards to patient care in the physiotherapy practice. As Branch (2000) mentions, if we ground our ethics in caring, we refocus on the doctor’s responsibility for the individual patient. The patient–doctor relationship and the communication therein once again become the starting point for all ethical discussions.
Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics. New York: Oxford University Press.
Bandura, A. (2006). Toward a Psychology of Human. Perspectives on physiological science, 164 – 180.
Branch, W. (2000). Ethics of caring and medical education. Acad. Med, 75: 127 – 132.