MEDICINE AND THE LAW

 

Patient abandonment in primary healthcare settings: What duty is owed to medical students?

 

 

N O Mapukata

MSc Medicine Bioethics and Health Law, MSc Health Care Management, ND & BTech Medical Technology (Cytology) School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town; and Department of Family Medicine and Primary Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Correspondence

 

 

---

ABSTRACT

Much of the literature on patient abandonment focuses on legal implications as an outcome of a unilateral premature termination of a health service without the consent of the patient. The plight of medical students is seldom considered in such instances. Two cases are presented that highlight the issue of patient abandonment during clinical rotations in primary healthcare settings and the impact on the emotional wellbeing of students. Systemic challenges are flagged for consideration, taking into account the projected annual increase in the number of medical students who must be integrated and trained to respond to the needs of South African patients.

---

 

 

Patient abandonment

The widely reported abuse of an elderly patient in a Gauteng hospital has once again highlighted the psychological trauma that is imposed on those who witness such events.^[1] Incidents of patient abandonment as reported by medical students are on the increase, despite an explicit commitment in the guidelines for professional practice that no one shall be abandoned by a healthcare professional (HCP) when they present to a public health facility.^[2] This commitment is premised on a relationship of mutual trust that exists between patient and HCP, as well as the moral contract that governs the relationship between society and the profession.^[3] Many of the publications on patient abandonment tend to focus on legal implications as an outcome of a unilateral, premature termination of a health service without the consent of the patient. This can constitute an intentional act or instances where the HCP was judged as being negligent,^[4,5] with links drawn between underservicing and abandonment.^[6]

 

Health service provision

In South Africa (SA), health service provision is a functional area for which the legislative competence is shared between the provincial and the national departments as provided for in section 4 of the Constitution of the Republic of SA.^[7] Initiatives to improve access to healthcare, which included the strengthening of district health services, devolved service provision closest to the point of care and decentralised medical training to primary healthcare centres (PHCs).^[8] While these initiatives are acknowledged as progressive and beneficial to the population, the country has been beleaguered by social and organisational challenges that have not abated despite the ushering of a new administration.^[9]

 

Clinical training of medical students

Medical education is the responsibility of designated institutions of higher education,^[10] but preparing students for healthcare practice is a shared responsibility that is regulated by the Health Professions Council of SA. Section 6(b) of the Health Professions Act 56 of 1974 makes provision for the clinical training of a medical student to include comprehensive patient care that is adaptable in response to changing patterns in healthcare.^[11] In that regard, the duty of care for medical students is extended beyond the university to include PHCs. Such arrangements have not considered organisational factors such as the poor management of public health facilities, which have not only affected patient management but have resulted in the dereliction of duty.^[1,9] Similarly, a charged sociopolitical environment in the context of a resource-constrained setting has placed medical training in a precarious position.^[10] Subsequent public healthcare system deficiencies have exposed medical students in training as vulnerable groups. In meeting the demands for healthcare provision, some students have had to operate beyond their scope of practice, leading to them coining the term 'pushing the line'.^[12]

 

Cases of abandonment

Two recent cases that were documented in the logbooks of medical students at two clinical sites as acts of negligence or of underservicing^[6] highlight the impact of abandonment on emotional wellbeing of students and harms that may accrue to the patients concerned.

Case 1

A 7-year-old boy, brought in by his mother, complained of stomach pains, vomiting and fatigue. The mother told me this happened every 2 - 3 months since he was 3 years old. I examined the child and immediately suspected neglect or even abuse, as he was very thin, dirty and fearful when examined. I saw multiple scars on his lower back, for which his mother could not give an explanation. I consulted with the doctor on call, who then referred the child for follow-up at the outpatient department the next day. There, the same doctor saw the child and his mother. A full examination was, however, not conducted, and the child was referred to a psychologist. I felt very helpless and I was emotional about the situation. I felt that this child was not properly assessed and that he might still be subjected to abuse/neglect. This made me question the ability of the healthcare team to safeguard vulnerable children. I was also left with much confusion about how these cases should be managed ... It is part of our duty as doctors, and even our moral duty as adults, to protect vulnerable people, including children.'

Case 2

'I had a look at a J88 form that had been completed by the attending doctor. I was horrified to see the lack of care that had been taken to fill out the form, which was unlikely to get a conviction and ultimately justice in court. I was disgusted at how little effort and commitment were shown to the patient if that is what we think of her effort and bravery in opening a police case ... This incident made me realise how some doctors fail in their duty to their patients.'

Breaches in the duty of care

While patient abandonment is mostly attributable to systemic failures, breaches in the duty of care are inexcusable as it is not possible to substitute HCPs with other categories of the workforce.'¹-The outbreak of the Ebola virus disease in 2014 highlighted many of the ethical challenges HCPs had to deal with. Although the outbreak exposed many of the limitations to accessing adequate healthcare,'^13-none of these were even remotely associated with abandonment. The morality and integrity that govern the contract between society and medicine are an outcome of cultivated behaviours that are modelled by HCPs'^10- and a work ethic that is observed by students.'^12-Notwithstanding a disease process, in settings where students are trained, abandonment not only violates the rights of patients to access adequate healthcare, this also has a direct impact on medical training that is compromised when students are forced to observe unacceptable or inadequate levels of healthcare.'^12-

 

Conclusions

Calls by the government for universities to accommodate an increasing number of medical students and the commitment to graduate socially accountable HCPs suggest that there will be many more students rotating through PHCs. Every effort should be made to ensure that PHCs are adequately resourced to meet the standards of clinical training. This is, after all, the duty of care that is owed to all medical students.

Declaration. None.

Acknowledgements. Gratitude is extended to the Wits medical students.

Author contributions. Sole author.

Funding. None.

Conflicts of interest. None.

 

References

1. Zulu S, Dlulane B. MEC Masuku to visit Mamelodi Hospital as family lays 'abuse' complaint. https://ewn.co.za/2019/06/02/gp-health-mec-to-visit-mamelodi-hospital-over-reports-of-patients-ill-treatment (accessed 3 June 2019).         [ Links ]

2. Health Professions Council of South Africa. Guidelines for Good Practice in the Health Care Professions. General Ethical Guidelines for Health Care Professions. Booklet 1. http://www.hpcsa.co.za/hpcsa/default.aspx (accessed 31 May 2019).         [ Links ]

3. Dhai A, McQuoid-Mason D. What does professionalism in health care mean in the 21st century? S Afr J Bioethics Law 2008;1(1):2. https://doi.org/10.7196/SAJBL.16        [ Links ]

4. Taber's Cyclopedic Medical Dictionary. Philadelphia: F A Davis, 2005.         [ Links ]

5. McQuoid-Mason D, Dada M. A-Z of Medical Law. Cape Town: Juta, 2011:1.         [ Links ]

6. McQuoid-Mason D. 'Over-servicing', 'underservicing' and 'abandonment': What is the law? S Afr Med J 2015;105(3):181-182. https://doi.org/10.7196/SAMJ.9141        [ Links ]

7. South Africa. Constitution of the Republic of South Africa, 1996.         [ Links ]

8. Mlambo M, Dreyer A, Dube R, Mapukata N, Couper I, Cooke R. Transformation of medical education through decentralised training platforms: A scoping review. Rural Remote Health 2018;18(1):4337. https://doi.org/10.22605/RRH4337        [ Links ]

9. Dhai A. Vulnerability exploited and a population betrayed. S Afr J Bioethics Law 2012;5(2):62-63. https://doi.org/10.7196/SAJBL.246        [ Links ]

10. Bateman C. Doctor shortages: Unpacking the 'Cuban solution'. S Afr Med J 2013;103(9):603-605. https://doi.org/10.7196/SAMJ.7323        [ Links ]

11. Health Professions Council of South Africa. Health Professions Act 56 of 1974. Regulations relating to the registration of students, undergraduate curricula and professional examinations in medicine. Government Gazette No. 31886:19. 2009.         [ Links ]

12. Mapukata-Sondzaba N, Dhai A, Tsotsi N, Ross E. Developing personal attributes of professionalism during clinical rotations: Views of final year bachelor of clinical medical practice students. BMC Med Educ 2014;14:146. https://doi.org/10.1186/1472-6920-14-146        [ Links ]

13. Dhai A. The Ebola crisis: Ethical challenges in the African context. S Afr J Bioethics Law 2014;7(2):42-43. https://doi.org/10.7196/SAJBL.359        [ Links ]

 

 

Correspondence:
N O Mapukata
ntsiki.mapukata@uct.ac.za

Accepted 13 June 2019