Rational decision making in medicine: 'Personal decisions are the leading cause of death' (3)

6 September, 2019

Dear All,

In our centre we are looking to do a small study of the notion that 'It has been contended that personal decisions are the leading cause of death and that physicians' decisions are responsible for 80% of health care expenditures.'.

Why?, because in the last week alone, we have been told of two deaths in hospitals that on the strength of the stories, are preventable deaths - both are previously well patients in their teens who were diagnosed as having Acute Appendicitis in the hospitals that they attended but died 48-72 hours later without having undergone surgery in that time.

The stories as often does, begin that the patient falls ill with abdominal pain, first tries self medication, when that fails (as with a brewing acute appendicitis), they visit either a religious house or retail patent medicine store (PMV) or a chemist /pharmacy shop. In both the PMV and the pharmacy they are given multiple drugs which would comprise antibiotics at least and a pain killer (commonly an NSAID). They fail to recover, and get worse, and then many days/ weeks later they are in a serious state, and they then reluctantly go to see a medical doctor in a hospital, just as with the two latest cases this week. The doctor does the routine clinical clerkship of an emergency case and well a, it is acute Appendicitis (with generalised peritonitis) like these two unfortunate cases. The real end-game drama then begins:

The Out of Pocket payment system is the most common where the patient must pay before treatment no matter how ill, but the patient / family / relatives have no money to pay at that time of emergency need. And there is no mandatory insurance cover for the population, to pay the providers / hospital. This occurs whether the patient is in a hospital that is public owned or private. The relatives are sent to find the money. Some 'distracting' investigations like Scans and a series of blood tests are also requested for this patient, who already has no money. A drip may be set up and colored with Vitamin B complex injection to look impressive.

The acute appendicitis is getting worse, the family is looking for money to pay for the operation. And before surgery the patient dies from complications of the condition a few days later, as happened with these two teenagers.

This scenario is the commonest in recent decades, and not the exception. Far from it.

This is why the notion that 'It has been contended that personal decisions are the leading cause of death and that physicians' decisions are responsible for 80% of health care expenditures.' really interest us, and we would like to study the dynamics that leads to these tragedies of loss of life when it can be prevented.

We agree with Neil when he says that '----------- empowering individuals with such information (reliable health information) would be a key enabler of rational decision-making and positive health outcomes.', but we believe also that it is more than just lack of information. There is a whole system failure at various levels fuelled by all sorts of complex other societal issues. We need to find out additional types of intervention that may be necessary, and at what levels should they be applied?:

1) what is it that makes even those patients / families who have information continue to take decisions that lead to their delaying access to skilled care?;

2) why is it that skilled health workers (including doctors and nurses, etc) who know the consequences of delaying appropriate care to an acutely ill patient, put money between an emergency patient and care, why do they take such unethical decisions?;

3) Why is it that the Patent Medicine stores and Retail Pharmacies continue to practice / dispense beyond their legal mandates, even when they know that the consequences are lethal for the patient?.

There are other questions but we shall stop with these three.

Joseph Ana.


@Health Resources International (HRI) WA.

National Implementing Organisation: 12-Pillar Clinical Governance

National Implementing Organisation: PACK Nigeria Programme for PHC

Publisher: Medical and Health Journals; Books and Periodicals.

Nigeria: 8 Amaku Street, State Housing & 20 Eta Agbor Road, Calabar.

Tel: +234 (0) 8063600642

Website: www.hriwestafrica.com email: jneana@yahoo.co.uk ; hriwestafrica@gmail.com

HIFA profile: Joseph Ana is the Lead Consultant and Trainer at the Africa Centre for Clinical Governance Research and Patient Safety in Calabar, Nigeria. In 2015 he won the NMA Award of Excellence for establishing 12-Pillar Clinical Governance, Quality and Safety initiative in Nigeria. He has been the pioneer Chairman of the Nigerian Medical Association (NMA) National Committee on Clinical Governance and Research since 2012. He is also Chairman of the Quality & Performance subcommittee of the Technical Working Group for the implementation of the Nigeria Health Act. He is a pioneer Trustee-Director of the NMF (Nigerian Medical Forum) which took the BMJ to West Africa in 1995. He is particularly interested in strengthening health systems for quality and safety in LMICs. He has written Five books on the 12-Pillar Clinical Governance for LMICs, including a TOOLS for Implementation. He established the Department of Clinical Governance, Servicom & e-health in the Cross River State Ministry of Health, Nigeria in 2007. Website: www.hriwestafrica.com Joseph is a member of the HIFA Steering Group and the HIFA working group on Community Health Workers.



Email: jneana AT yahoo.co.uk