Dr Niyaf's Online Clinic

This is my personal opinion and it is independent of any official IGMH position. And for the record: the system has since changed back to the old system.

I read a news article on Haveeru Online. It presented an interview with an official from IGMH regarding a change to the OPD appointment system starting from 1st February 2009. The change, apparently made after discussions with relevant staff (I was, sadly,  considered irrelevant), was to stop doctor specific appointments. That is; you would no longer be able to get an appointment for a specific doctor by name. Instead patients will be provided the next available appointment slot for the related department dealing with the kind of illness. It could be for any doctor of that department.

I certainly would have voiced my concern had I been included in the group of relevant staff. Perhaps the fact that I am away from IGMH, on official leave, was the reason my opinion was not sought.

I believe the new system is not in the best interest of the patients. It is likely to force many patients to turn to private clinics to be able to consult the doctor of their choice. It is no wonder that many common people are speculating this as the intended reason for the change. 

Why do I believe that not allowing doctor specific appointments is against the best interest of the patient?

Diagnosis may not be possible in a single consultation.

I agree that a large number of patients who present to hospital suffer from relatively minor ailments that are relatively easy to diagnose. Perhaps some of them could be diagnosed in a single OPD visit and treatment advised.  In some of those cases a follow-up may not be needed.

However, a significant number of patients have illnesses that require more than a single visit for diagnosis and institution of the required treatment. Some of them may need to have investigations done to help establish diagnosis. Others may need follow-up after a few days of instituting therapy to assess the response so that therapy could be modified where response is not as desired.

In these situations having to see a different doctor at each visit could be frustrating for the patients. Each doctor may need to start from the very beginning, repeating many of the things already done by the other doctor at the previous visit; like repeat of history.

Having the opportunity to consult the same doctor with the reports or after initiation of therapy is therefore better for the patient and the doctor.

Continuity of care for Chronic illnesses.

Some illnesses have a long course, even with treatment. Some may have recurrent episodes of illnesses while others maybe lifelong. In these situations continuity of care is absolutely vital for proper care.
The system being proposed prevents this kind of continuity of care. It opens up the possibility of unnecessary alterations to treatment and therefore prolonging the ailment. 

Not all doctors within a department have the same capacity.

Some doctors within a department may be better dealing with certain specific types of illnesses than others. This is recognized among doctors within a department as well. It sometimes happens that we refer patients between each other because of this reason. 
Some doctors may have had extra training in specific areas, in addition to the specialty training of the department. We have some specialists who have acquired extra skills and knowledge specific to a sub-specialty field. For instance a physician may have extra skills in treating Diabetes or Kidney diseases. In such cases, being able to refer patients or guide them to one of these people, where the need exists is likely to be more rewarding to the patient. This wouldn’t be possible with the new system at IGMH.

In addition to these, there are various other reasons why a patient may choose to or prefer to consult a specific doctor; like past experiences with a doctor could prompt a patient to either prefer a specific doctor or not.

I believe that the system needs to change to allow for an opportunity to allow patients to seek consultation with a doctor of their choice. I would support having some OPDs where patients are able to get appointment by a walk-in system. Such OPDs as OAPC (Open Appointment Pediatric Clinic) and Walk-In OPD at the internal medicine department were doing this even before. Perhaps they need to be managed better to improve its value to the public.

I urge the IGMH administration to reconsider the changes and come up with a system that indeed is in the patients best interest.

Responses and Discussions:

•  Yasiph wrote:
  1st para: you said you were sadly considered irrelevant
  2nd para: you happen to know why your opinion was not sought.
  Why make a fuss out of it?
  
  Isn’t there just anyone except you who feel this isn’t right! Where’s MMA?
  
  IGMH never had a system that is in the patient’s best interest! Why now, or ever!

• Anonymous wrote:
  I hate this change in IGMH, I have a 3 yr old who is an asthmatic patient, since birth i have been consulting him to one specific doc of my choice. 
  Now cause of this change i wont be able to consult him to the same doc unless i go to a private clinic and spend more money, It seems like now v dont have the right to consult our kids and us to docs of our choice…. Where is human rights?>……..is this the changes that maldivians need, what to do all the poor ppl r suffering …. pls ppl reconsider this matter pls
  
  
• Niyaf wrote:
  Yasif,
  
  Even while I am away I continue to provide my opinion to the admin at IGMH. It is up to them to decide if it is useful or not. But I make it a point to contribute to the best I can my views. I do not want you or anyone to believe that my opinion is more important than those of others, but it is definitely not less important either!
  
  At IGMH we have internal email, which sadly isn’t being used for communication such as seeking opinion from staff regarding issues. It should be. 
  In the 2nd paragraph I am trying to think from their perspective (see I have used the word Perhaps) to see if I can explain why.
  
  I fuss about it because poor decisions are being made and the public is being misinformed that this was done after discussion with everyone! More than that, I am totally fussed about it because, patients stand to lose if this new system is allowed to continue in its current form.
  
  I am pretty sure that other people too have opinions. But over the past many years people had become afraid to voice their concerns due to inevitable reprisals. That fear is still there. The way things are turning out against those who voice their opinions, even today, one may say that the fear remains. Perhaps a legacy of yester-years.
  
  I am not sure what MMA is doing about it. I am away from Male’ for quite sometime now. I hope they are doing something too. They must. We must. I think even the public must. These issues are far too important not to speak about.
  
  Why now? It is not only now. I guess you know a bit more history to say why now to mean: why am I bothered only now! I have been speaking out before, do now and will continue to do so. But again, why now (collectively for everyone) has a reason too: when plans are being set in motion that would almost definitely make things worse more people would come out and speak.
  
  I’d also like to hope that with the new government we should make it a habit for us to speak up and for them to realise that they must hear us and heed us as well. This is an opportunity to get the public to be more assertive and I’d like to at least try than to sulk 30 or so years later!

• Augmentin wrote:
  Dear Dr Niyaf
  1.In Maldives the health systems provide a lot of choice to the patients in selecting their doctors. It may not be sustainable over the long term. Instituations like IGMH has to undergo a tough love approach to implement systems that optimizes patients consultations and care. 
  2.The MOHF should start a GP system where everybody will have a family doctor in opartnership with the private clinics
  3.regarding continiuty of care it is hightime departments in IGMH start using STGs so everybody is on the same page.

• faisal wrote:
  There are several problems with the new system, ranging from the basic right of a patient to choose his doctor to issues of confidentiality and privacy. Why this got the OK to be implemented in the first place raises questions of credibility and capability of the current administration’s health care policies. As a doctor I strongly oppose this.
  
  
• drhameed wrote:
  Since when did the doctors at IGMH consider patients. Its always your self intrest first then the patients. The reason that IGMH is so hated by the general population is the internal politics of its maldivian doctors.After studying on public funding your lot don’t seem too eager to serve the public yet you squeeze every penny out of people who don’t have any other way. The roster now being planned i see has a Doc as the head trying to divert the benefits of peoples illnesses to your clinics. I don’t know you but this is my view in general of doctors who serve at IGMH. /thanks

• Niyaf wrote:
  Hi drhameed (I have a feeling that, that is not your real name. I maybe wrng though),
  
  I cannot speak for all doctors at IGMH. But I think it is very unfair to put all doctors in that one basket. I can assure you that there are many doctors who are kind, caring and very committed to their profession. Some work terribly hard to try to do what is right. Unfortunately, what is right for some is almost alway wrong in another persons perception.
  
  Most public service institutes in the country need to re-invent themselves as service-providers. IGMH is perhaps one institution that needs to do the greatest work.
  
  I understand that there are reasons why you and many others have these opinions regarding IGMH and Maldivian doctors working there. I hope you’ll accept that there are people who try to do the ethical and right thing too. They don’t succeed much often though. It is disheartening for them. But they continue to try nonetheless.
  
  I don’t have an answer for every problem that IGMH has. But I think we can start off by listening to the workers and those we are serving; the public. I understand that we probably will never be able to satisfy everyone. Simply because the needs and views of people are so diverse. Perhaps more transparency in decision making, increased involvement of real stakeholders in that process and improved public relation (not just having a “complain here” counter) could help a great deal.
  
  Some amount of internal rivalry and politics is probably helpful (I could be wrong but that is my current belief). But that has to remain within healthy limits.
  About private practice; I do private practice too. And I know some of my patients whose parents would prefer to see me in the clinic rather than IGMH. Some prefer it because of convenience. Other prefer because they get to spend more time with me at the clinic than they’d be able to at IGMH. This happens because at the clinic I limit the number of patients I see over a 3 hour period to 12. That is 15 minutes per patient. In the same amount of time at IGMH, the admin wants me to see 20 patients (maybe even more). It is a difficult balance between quality and quantity; both are important but for me quality is what I am not willing to compromise on.
  
  Going to clinic is not only about making more money. The extra income is useful and I don’t say that I don’t make money from working at a clinic. But it is also an exertion for me. It is time I could otherwise spend with my wife and kids. It give me an opportunity to practice OPD medicine with less time constraints and pressure (That I think makes my patients happier and they then get more return for their expenditure). So, it is not all about money. Not for me anyway.
   
  I just hope that we could have more services at IGMH and other health care outlets that are to the likings of our people. I wish that those people who hold the authority positions in the ministry and the institutions would heed the opinions of the people.

(Source: blog.niyaf.com)