I was on my 3rd block this year in Mitchell’s Plain Intermediate Care Facility/ Aquarius Health Care, it was a specific neurology rehabilitation block. In this facility there are 3 wards and each ward is divided into 6 rooms that has about 8 beds per room. I had 7 patients that were designated to me for 6 weeks to see them everyday, and 2 of these patients were in the same room and their beds were close to each other, both of them had a cerebrovascular accidents and they were in  different levels of rehab. The important detail about these 2 patients is that one was a foreign national(Patient X) and the other was a South African citizen(Patient Y), so normally I would see them after lunch partly because their ward was very far from the department, this meant I only had an hour to see them. The other factor is that I would always start by seeing patient X because his bed was next to the bed. 

All that I have mentioned above was not a problem until Patient X formally requested a leave of absence on  Monday, where he would go home for the weekend and come back on the following Monday, well 2 days later also patient Y requests a leave of absence as well. The problem was both of these gentlemen needed my approval for their requests to be accepted, so I consulted my senior clinicians and we collectively came to a decision that only Patient X was ready to have  leave of absence, based on the fact that he was on a better level of rehabilitation and had a firm family support structure while both of them needed walking aid, Patient Y was in a much more dependent state and his family had not agreed on taking care of him for the weekend. On a Thursday morning, I informed patient X about the final outcome of his request and I was going to inform Patient Y later, but since they share the same room space, Patient X obviously excited, told Patient Y about his outcome, So when I came to break the news to Patient Y about him not getting his leave of absence for the weekend, he was excited hoping it’ll be same new for him as well, unfortunately it was not. He  did not like it and he ended up saying things like, “I did not go home because you prioritized a man from another country over an original citizen, how could you do that? You always help him first and you make him walk while you only make me stand” and he said a lot of things that were highly unacceptable, even though I tried to make him understand the decision process involved all the intrinsic and extrinsic factors that contributed to the outcome. 

So the following week I had to treat the same people, and at that time, in my mind I was so uncertain  and critical of myself during treatment sessions, like asking constantly asking myself whether am I spending enough with patient Y, Is my face friendly enough for him etc. So now, when I look back on this experience, I realize that it connects to the 2 main topics, Just resource allocation and Ethics and Professionalism. The first part about Just resource allocation, which is in this case consists of time, therapy and a walking aid, the first obvious factor that contributed to this situation is micro-resource allocation, it is nearly impractical to effectively treat 7 patients in a span of 5 hours, especially in a neurology rehabilitation setting and this point back to insufficient staff. The second factor is meso-allocation of resources, at that institution the rule was that we can only see patients after 09h00 and at 10h30 there was a 30 minute tea time followed by a 1 hour lunch at 13h00, this heavily affected the therapy arrangements for patients. The factor can be attributed to the macro-resource allocation, because the whole ward had 6 walking frames that can be used for mobilizing and for a leave of absence if its needed. The other factor that probably played a role as well is implicit bias, it is highly likely that I used to see patient X first because he was showing much better signs of progress and with neurology patients the rehab process is so slow in a way that the improvement is noted after a long period of time and that may have pushed me to focus more on Patient X as he was showing notable signs of improvement, and seeing improvement does motivate you as a therapist. This possibility does make one wonder, if this is actually a thing, then How can one combat it? Can one be blamed for such?

Most of the literature that explores implicit bias, focuses so much on race, gender, age and common stereotypes. Like the systematic review by Dr C. Fitzgerald and Dr S. Hurst that concluded that there is a substantial evidence that implicit biases affect the patient outcomes and are mostly associated with race, gender and age(Fitzgerald & Hurst, 2017), in their recommendation they revealed that this is an area in need of more uniform methods of research to enable better comparison and communication between researchers interested in different forms of bias. Important avenues for further research include examination of the interactions between patient characteristics, and between healthcare professional and patient characteristics, and of possible ways in which to tackle the presence of implicit biases in healthcare(Fitzgerald & Hurst, 2017). 

On the professional aspect, The Merriam-Webster dictionary defines professionalism as “the conduct, aims, or qualities that characterize or mark a profession or a professional person;” and it defines a profession as “a calling requiring specialized knowledge and often long and intensive academic preparation(“Definition of PROFESSIONALISM”, 2019). These definitions imply that professionalism encompasses a number of different attributes, and, together, these attributes identify and define a professional.  To explore professionalism further, in the concept of healthcare, the American Board of Medical Specialties (ABMS) defines professionalism as a belief system in which group members (“professionals”) declare (“profess”) to each other and the public the shared competency standards and ethical values they promise to uphold in their work and what the public and individual patients can and should expect from medical professionals. At the heart of these ongoing declarations is a three-part promise to acquire, maintain and advance: (1) an ethical value system grounded in the conviction that the medical profession exists to serve patients’ and the public’s interests, and not merely the self-interests of practitioners; (2) the knowledge and technical skills necessary for good medical practice; and (3) the interpersonal skills necessary to work together with patients, eliciting goals and values to direct the proper use of the profession’s specialized knowledge and skills, sometimes referred to as the “art” of medicine. Medical professionalism, therefore, pledges its members to a dynamic process of personal development, life-long-learning and professional formation, including participation in a social enterprise that continually seeks to express expertise and caring in its work(ABMS, 2012). these two definitions show the depth of possible understanding of professionalism between someone who is not in the healthcare field and a healthcare professional. This leads me into acknowledging a possibility that a patient may accuse a healthcare professional of unprofessionalism and incompetency while a healthcare professional may believe he/she has ticked every box concerning acting professional towards patients. this posits a question, what can be done about this gap? yes patients are consistently taught about their rights and responsibilities, but there is little to none effort being applied in ensuring that patients fully understands what constitutes a professional behavior for healthcare providers.

A study that was conducted by Eljse Scheiffer, Surona Visage and Marguerite Schneider on the impact of health service variables on healthcare access in a low resourced urban setting in the Western Cape,South Africa found that the lack of resources, equipment and enough staff in the CHC’s leads into patient’s believing that the quality of service is substandard and the level of professionalism is very low, due to the fact that they do not get the devices or equipment they need and on interactions with healthcare workers, they are not satisfied due to the staff appearing carefree and tired (Scheffler, Visagie & Schneider, 2015) .

A study that was conducted in Romania about patients perceptions of healthcare professionalism found out that most patients associated friendliness of the staff with high professional standards and a significant portion of the patients associated low professional standards with responsiveness of the healthcare workers to their demands and their overall mood(Propa. D, Drugus D, Leasu F & Repanovici A, 2017). This shows that most patients associate the mood of the healthcare worker with professionalism, So it is not about what you do, it is about your face when your do what you do. another study conducted in a South African context, about the perception of patients of the professionalism of dental students at a Tertiary Oral Health Center, which found out one of the things that patients deemed not very professional was the mood or the facial expressions of dentistry students during interactions (Malele-Kolisa, de Ponte, Lee, Vala & Gosai, 2018). these two studies show that most patients do not understand into greater details the concept of professionalism, especially when it comes to micro-aggressions.

In conclusion, the case above shows the need to level the patients with what a professional behavior is expected to be, but most importantly this case shows how one aspect of healthcare delivery problems such as lack of resources can lead to another one that affect healthcare workers at different levels and in all of that, they are still expected to provide the very best care. Which is why I chose the multimedia I used, with everything falling apart we are still expected to stand tall and deliver.

References

Definition of PROFESSIONALISM. (2019). Retrieved 16 September 2019, from https://www.merriam-webster.com/dictionary/professionalism

FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: a systematic review. BMC Medical Ethics, 18(1). doi: 10.1186/s12910-017-0179-8

F. W. Hafferty M.Papadakis, W Sullivan, M. K. Wynia, American Board of Medical Specialties ; medical professionalism 2012

Popa, D., Druguș, D., Leașu, F., Azoicăi, D., Repanovici, A., & Rogozea, L. (2017). Patients’ perceptions of healthcare professionalism—a Romanian experience. BMC Health Services Research, 17(1). doi: 10.1186/s12913-017-2412-z

Malele-Kolisa, Y., de Ponte, G., Lee, C., Vala, C., & Gosai, P. (2018). The perception of patients of the professionalism of dental students at a Tertiary Oral Health Centre, South Africa. South African Dental Journal, 73(10). doi: 10.17159/2519-0105/2018/v73no10a3

Scheffler, E., Visagie, S., & Schneider, M. (2015). The impact of health service variables on healthcare access in a low resourced urban setting in the Western Cape, South Africa. African Journal Of Primary Health Care & Family Medicine, 7(1). doi: 10.4102/phcfm.v7i1.820