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Monday, December 22, 2003

Observation Must be Seen

The Commonwealth Observer Fluke

Dr. Lester CN Simon

Have you read the official report on the 1999 general elections in Antigua and Barbuda by the Commonwealth Observer Group? You should. When you read it, please put aside your political allegiance. Try to read it dispassionately to determine if the Group fulfilled its terms of reference. You may find that it gets a score of only 66.7%, not enough for a distinction.

The Group’s terms of reference include three essential tasks: “To determine in its own judgment whether the conditions exist for a free expression of will by the electors and if the results of the elections reflect the wishes of the people… [and] propose to the authorities…..such actions….as would assist the holding of elections”.

Regardless of your political persuasion, you must be dissatisfied when you read the conclusions and recommendations of the Group. The conclusions note that the “electoral process we observed on polling day had allowed the people of Antigua and Barbuda to freely express their will at the polls…” So far, one out of three (33.3%). Remember, the judgement is that of the Group, not anyone else’s. Put your political persuasion aside.

In addition, the Group pens a long list of recommendations, a number of which are “in line with those contained in the Supervisor of Elections’ report on the 1994 general election”. So far the Group gets two out of three, with no extra points for “cogging”.

Strangely, the report does not issue a single word about whether “the results of the elections reflected the wishes of the people”. It failed miserably this part of the examination. Nought! This raises the question: How did the Group plan to determine, as objectively as possible, the wishes of the people? Put your political persuasion aside.

Indeed, how can anyone determine this? Try to be unbiased in your answer. Assessing the wishes of the people may not be as simple as it seems at first. At its most rudimentary level, it involves a combination of factors and observations which cannot be undertaken, together with the other aspects of the terms of reference, in 8 days. The Group arrived in Antigua on March 4, 1999 and departed on March 11, 1999.

The Group should have paid more attention to its terms of reference. It should have worked harder and longer to answer all three compulsory questions. We are taught to read the instructions at the start and during the middle of the examination. Some even read them at the end and beg an extra half mark by noting that they misread the instructions.

And as if to add salt to salt fish, the Group showed its poor powers of observation of local politics when it allowed the colour of the cover of its report to be blue! Was this a veiled reference to the wishes of the people? No! No more than the Group expected the report to be “read”! The Group simply blew the most crucial aspect of its terms of reference.

Monday, October 20, 2003

Feeling Sick


Dr. Lester CN Simon

Is it impossible to make some sense of the transition from Holberton Hospital to the Mount St. John Medical Centre (MSJMC)? Is it possible to say something enlightening and useful? Something to assist in formulating a roadmap for the resolution of the complex management problems confronting us? Of course it is. But there are at least three basic requirements: a sense of history, a sense of humour, and a good dose of common sense.

The central thesis of this article is that no one in this country is ideally qualified to work at the MSJMC. No one. If this is true, it makes sense to create a road map that is more inclusive and to draw back from the silly notion that suggests that there are a few, chosen people who know everything.

Let us start near the top. Imagine yourself as the Chief Executive Officer (CEO) coming to Antigua and Barbuda from North America. The main reason you would undertake this job is for the challenge it throws up. It is not just a new geographic territory for you; the entire management system that is required is new to you and to the locals. You cannot simply recreate the USA system.

The old local system has many faults and an altogether new system catering for local idiosyncrasies must be forged. However, we must not pay any attention to the sentimental notion that we have to accept less here simply because we are a developing nation. There is a minimum standard of health that guards against unnecessary sickness and death. This requires a new, improved, complete and all-inclusive approach to management. So who on earth was mad enough to talk about nurses undergoing a probation period as if they were the only ones venturing into this new environment? It’s probation time for all of us including the CEO.

Our next stop is to look at the medical management of Holberton and take a peek at the proposal for the MSJMC. The modern history of medicine in Antigua and Barbuda seems to have begun in the late 1970’s and early 1980’s when an increasing number of local doctors returned home from studies overseas. Imagine yourself as a bright, young, committed and enthusiastic doctor coming home with new ideas and dreams of a new hospital. You do your research as any good doctor would.

You find a number of the Annual Medical and Sanitary Reports from the 1950’s to the 1970’s. The 1957 edition noted, “The combined post of Medical Superintendent and Surgeon Specialist was abolished at the end of 1956 and instead a Medical Superintendent was appointed, while the post of Surgeon Specialist continued as a separate entity from the 1st January, 1957”.

In 1973, Dr. C.E.S Bailey was the Chief Medical Officer and Mr. George Jamieson was appointed Hospital Administrator. This was a newly created post and the former post of Medical Superintendent was abolished. Mr. Jamieson, a non-Antiguan, was appointed for two years. Two local candidates were in training as Hospital Administrator, viz,
Mr. Ryves Merchant, who went to Britain and Mr. Dorbrene O’Marde, who studied in Canada.

In 1974, Mr. Merchant was appointed as Deputy Hospital Administrator. Some time after 1974, it is alleged that Mr. Merchant became the Hospital Administrator and
Mr. O’Marde became his deputy. It is also alleged that one of them was subsequently transferred to the Ministry of Agriculture and the other one was sent to the Ministry of Culture. Can one assume that this dislocation was part of a grand insightful medical benefit scheme to offset the sickness that would later attend these two ministries? Or was this the first serious episode of the disarticulation of medical benefits so that up to now we still cannot put our medical benefit monies in our medical benefit mouths?

In 1974, a feasibility study was carried out for the provision of a new general hospital to replace Holberton Hospital. The British team of experts, which included the Medical Advisor, Dr. J.A. Oddie, delivered their report to the government for consideration and approval. The need for a new hospital such as MSJNC is not the bright, novel idea of this century, despite the numerous stories to this claim.

In 1983 (when I returned to Antigua and Barbuda), and probably before then, the post of Medical Superintendent had been re-established. The Medical Superintendent seemingly had a direct line of communication to the then Prime Minister. Disentangling the combined post of Medical Superintendent and Surgeon Specialist in 1956, appointing a Hospital Administrator and abolishing the post of Medical Superintendent in 1973, re-creating the post of Medical Superintendent, appointing and then “disappointing” and re-locating two trained hospital administrators, suggest that the management of Holberton Hospital was a perennial problem.

Enter the dragon, you might say. Or, if you prefer: The Return of the Jedi. Time to clear up all this confusion, build a new hospital and take us into the New Millennium. The first roadblock is the empire of civil service bureaucracy. It’s impossible to get the simplest thing done using these channels. But this is health. You have a direct line to the Prime Minister, just like the previous Medical Superintendent. Were it not for this, you would go crazy trying to effect the kind of health service we desperately need. Channels have to be circumvented because the empire of bureaucracy is too circuitous and it seems designed to frustrate everyone, including the very patient who is at the heart of any health service.

How could you involve all the other doctors when the usual reply when they were approached on any matter was: The obstetricians thought you were labouring under a misconception; the dermatologists preferred no rash moves; the cardiologist didn’t have the heart to say no or yes; the urologist felt the scheme wouldn’t hold water; the opthalmologist considered the idea short-sighted; the orthopaedists always wanted a joint solution; the pediatricians wouldn’t grow up; the Ear Nose and Throat surgeon, despite his bounteous musical skills, would not listen, he always smelled a rat and he could not swallow the idea since it got stuck in his throat; the other surgeons washed their hands of the whole thing and the pathologist, of all persons, the one who had a hard time building the lab and who should know better, yelled, “over my dead body”!

So you finally succeed in building a new state-of-the-art hospital. In the process you are blamed for some things you have done and even for some things you have not even dreamed of. Such is the price, or is it the cost, according to one of the POWA ladies? So how are you configured in the management of this new MSJMC?

There are many routes to becoming a Medical Director----no more of that Medical Superintendent, British nomenclature nonsense. You do your research. You find two key articles called “Executives in White Coats”, by Drs. Bodenheimer and Casalino published in 1999 in the New England Journal of Medicine (NEJM). The article noted that during the past two decades a new breed of physician called the medical director has emerged, with substantial influence over medical practice.

In answer to the key question of the routes by which they come to their jobs, the two doctors interviewed 50 medical directors. Examination of the career paths of medical directors revealed that membership in the American College of Physician Executives grew from 64 in 1975 to 14,000 in 1998. Medical directors arrived at their positions through a clinical path. Most of the medical directors in the study had spent many years as clinicians, had then taken on some part-time administrative duties, and had gradually increased their administrative responsibilities and reduced their clinical activities. Another study had found that the average medical director spent 16 years in clinical practice before assuming a management role.

During the early years of managed care, few medical directors had business degrees. Most learned their administrative skills on the job. Gradually, more physicians interested in administrative careers began obtaining graduate degrees in business. These include master’s degree in business administration, in medical management, or in health administration. Most of the medical directors with a strong clinical background interviewed in the NEJM study, found formal training in business very useful.

The NEJM article also noted that the business path to medical directorship involves a few years in clinical practice and emphasis on administrative more than clinical acumen. Indeed, medical students can now earn a five-year M.D.-M.B.A. degree and become physician executives without ever seeing a patient outside the training program. So who on earth was mad enough to talk about nurses undergoing a probation period as if they were the only ones venturing into this new environment? It’s probation time for all of us including the Medical Director.

Let us now look at the worst possible worker at Holberton: the uncooperative, the lazy, the inefficient, and the absolute worst. You do this not to excuse these workers but to understand them. This is essential because as the number of such workers increases you have to wonder why they behave that way, especially since you know that they were once cooperative, reliable and efficient workers. You consult the experts on management.
You ask them about money and motivation. They tell you that getting more money simply motivates you to get more money. Effective motivation factors include elements like achievement, recognition of achievement, advancement and growth.

One of the core assets of the hospital or any workplace is the intellectual capital of the workers. So what do you think will happen when we the workers are not made an integral part of the plant, when they do not take our suggestions on board, when we feel apart from, instead of a part of, the workplace? A vicious cycle is created in which, without knowing our history, we seemingly become constitutively unproductive. But the majority of us who make the most noise and give the most trouble are actually crying out for help! The disinterested, quiet ones may actually be fooling you. If we need probation, I hope they hire an industrial psychologist because management and ministry and all of us need a probationary period to learn how to work together. This synergy is the physiology of productivity. We are not horses running wild in disarray around a racetrack.

In 1957, there were 139 beds at Holberton, which amounted to 2.7 beds per 1,000 population. Two years later, there were 180 beds or 3.5 beds per 1,000 population.
The 1972 Annual Medical and Sanitation Report recorded the population census as
64,794 people and it noted that Holberton Hospital had 216 beds. These data amount to 3.3 beds per 1,000 population in 1972.

It was reported in a local newspaper that an official of the MSJMC said that the bed capacity at MSJMC would be 186. The total de facto population listed in the 2001 Preliminary Census Report was 77,426. These two data amount to 2.4 beds per 1000 population when MSJMC is opened in 2004 compared to 3.5 beds per 1,000 population in 1959 and 2.7 beds per 1,000 population in 1957.

Let not your heart be troubled. The key to get around this decrease in beds per 1,000 population is that the average length of stay in MSJMC will be much shorter. With a markedly improved bed turn over rate, the present lower bed per 1,000 population will not affect the efficiency of the MSJMC negatively.

But this raises the important question of the relationship between MSJMC and the rest of the health service since bed turnover rate and patient recovery are dependent on factors within and without the hospital. It underscores the fact that for MSJMC to function efficiently and effectively, there must be a complete reformation of the entire health service in Antigua and Barbuda including public and private clinics and indeed public and private healthcare in general.

Indeed, I tried to compare the proportion of hospital beds per 1,000 population using data from PAHO Epidemiological Bulletin, Vol. 21, No.4, December 2000. The comparison is difficult because the article does not declare whether the number of beds refers to only acute care general hospital beds or if psychiatric and geriatric hospital beds are included. Nonetheless, an article by Valerie Nelson (December 31, 1997 in NurseWeek) started thus: Quick, a little Health Care 101: How do you measure the size of a hospital? If you answered, "by the number of beds," step to the back of the class. That answer’s years behind the times.

The article continued: “Hospitals now deliver so many different kinds of services that it’s almost hard to tell what a hospital is," said Paul Torrens, MD, professor of health services at the UCLA School of Public Health. It’s no longer a question of beds, but of what services a hospital is trying to deliver, he said. Thinking about how many beds a hospital needs ties into "the whole nature of the way health care is changing," Torrens said. Healthcare services, once separate entities, now are connected like so many lights on a string. Hospitals are becoming part of integrated delivery systems that are a far cry from the past, when the different facets of health care—prevention, outpatient services, nursing homes, home care—operated independently.”

Looking towards the future the article noted thus: “In the next five to 10 years, the traditional role and structure of the American hospital will be expanded and re-examined, Torrens predicts. New models will spring up that "are much broader and offer a much wider range of services than the old hospital," he said. The healthcare model developing around the nation is a continuum of services in which the hospital is a large cog in the [wheel] and "there is much more integration of services across lines," Torrens said.”

What is the view of the American Hospital Association (AHA)? The article concluded: Hospitals in urban areas that are duplicating services "gets to the whole issue of ‘what does the community need?’ " said Carol Schadelbauer, spokesperson for the AHA. Working together is what it will be about. A record number of hospital collaborations and mergers are helping to fuel the downsizing trend, she said. Did I hear you ask: Where are the public clinics, Adelin Medical Centre, and other private medical facilities in this national picture?

The same empire of bureaucracy with the mass of workers that was bypassed, to try to manage Holberton and other public health facilities, on the way up to Mount must now be confronted on the way down. The empire strikes back. The empire can only be defeated by a meaningful, combined attack involving a fairly constituted board, top management officials, the head of departments and representatives of the workers, rather than the occasional sortie and sally against the empire using handpicked, compliant generals.

The alternative is a continuation of the status quo, with overemphasis on outside assistance, which will only incur the charge of foreignization of MSJMC. If the better of the aforementioned actions is not undertaken, you will have to raise your head to the sky and bawl out: Jah! Rastafari! What have I done? What have I done?