Behind every academic paper there is a story. A story that motivates people to want to know more about, and better understand a specific reality. SURG-Africa is working with Dr Bip Nandi and his team on their study on how consent forms for surgical procedures are understood by patients in Malawi. Taking advantage of meeting at the 20th COSECSA Scientific Conference & AGM last December in Kampala, we decided to ask him a few questions about his research so far.
Dr Nandi started his work in Malawi in 2012 at the Queen Elizabeth Central Hospital, in Blantyre. He remembers his first months there as a period during which he was orientated with the working methods and idiosyncrasies of the place. “I tried my best to observe for the first six months, not to attempt anything different”, he recalls.
But on September of that year, an encounter with a woman and her sick child triggered a dilemma for him: how and what to communicate with patients before a surgical operation.
This incident made Dr Nandi question what did he do wrong, if anything at all, and moved him to conduct research on how guardians of children undergoing surgery understand the information received about the operation, and if that understanding is reflected in the consent form they have to sign as an authorisation for it.
Dr Nandi—currently working as a Consultant Paediatric Surgeon at Kamuzu Central Hospital in Lilongwe—believes that better methods of communication can improve comprehension issues, but can’t take them away completely. “Consent is challenging in high income countries, but even more so where I work. Our patients have different experiences, values and education. This makes it difficult for us to comprehend what information they need before before giving consent. Discussing the possibilty that your child might die during surgery is difficult in any setting, but we should not presume that what works in one environent is appropriate for another”, he assures.
Malawi has a population with a considerable number of illiterate people —many of the patients sign the consent form using their fingerprint. Furthermore while in Europe we are used to being informed of all possible implications that may occur during a surgical procedure, Dr Nandi wonders if that is something their patients need or want to know. “Our patients have a different worldview, not just to myself who is not a native Malawian, but also to most Malawian doctors” —he explains—, “I am not sure if we would be able to comprehend how they see the world so we mustn’t presume that we know what they want to know”.
In Malawi it is therefore important to take into consideration the powerful social context which influences consent. The best medical solution for a health problem might not be the most socially accepted choice, and that has an effect on the decision a patient makes when knowing about the outcomes of a surgical procedure.
An example of this is the case of a 12 year old girl who was bitten by a snake. By the time she went to the hospital, they tried to remove the dead tissue and clean the arm but it was already too late. Following consideration, and in consultation with other specialists, Dr Nandi talked with the parents about the conditions of the arm and the need for amputation. The parents, after their initial reluctance, finally accepted to go ahead with the procedure and signed the consent form. However, the day before the operation, they disappeared.
Dr Nandi and his team have already analysed their preliminary research findings. On the basis of their unprecendented results they are in the process of organising a second study. He hopes to be able to present the final results in the next COSECSA event that will take place in Lusaka at the end of 2020.
In 2015, in the case Montgomery v Lanarkshire Health Board —brought forward by a woman who experienced complications during the delivery of her baby—, the British Supreme Court pronounced in its sentence, in reference to information and consent that, the aim of the doctor’s advisory role is to make sure that patients understand the benefits and risks of the treatment and the possible alternatives, so they can make an informed decision. “The doctor’s duty is therefore not fulfilled by bombarding the patient with technical information which she cannot be expected to grasp, let alone by routinely demanding her decision on a consent form”, the sentence says.
Such judgements highlight the necessity of Dr Nandi’s initative to develop a better understanding between medical staff and patients. This becomes of major importance when referring to people living in rural areas where communities are more vulnerable and trust is the driving force that lead them to ask for assistance.