Too many women and children continue to die and this signals that something is systemically wrong with the country’s health system, says new head of the Medical Council of Guyana Dr Vivienne Mitchell-Amata, who said the answer lies in improving the competence of our medical practitioners.
Dr Mitchell-Amata, a trained anaesthetist specialist who is attached to the Intensive Care Unit of the Georgetown Public Hospital (GPH), said that the percentage of maternal and child health deaths is usually used as an indicator of the quality of health care in any country. She said the Health Ministry has a very good maternal and child health manual and if that is followed mothers and babies’ lives would be saved. From the outside, however, she does not understand where the “breakdown occurs, but there is a breakdown.”
If a pregnant woman who is “young, fit and healthy” cannot be saved, then what happens to someone who is older and is suffering from a chronic disease.
She called for better skills to conduct forensic analysis in getting to the root cause of the death instead of “doing a reactive thing in trying to push blame and so on, then it would recur which has been happening.” For her, many times the underlying problem is the system, even though she revealed that there are cases where had the doctor acted differently the patient’s life could have been saved.
There is also need to go back, “start from beginning because our children are being raped and we are doing nothing about that… they are getting pregnant and then two years down the line they are coming back pregnant; our children are using abortion as a form of contraception…”
The tough-talking President in an interview with the Sunday Stabroek revealed that there are a number of ideas she wanted to work on during her two-year tenure as the head of the council, and top of the list is improving the competence of doctors and ensuring that foreign doctors who work in Guyana are fluent in English. She says there is a great group of persons on the present council – they have all been there before – and they plan to get some of these issues dealt with.
‘Fluent in English’
“Any doctor coming to work in Guyana must be fluent in English and must be able to communicate with patients,” the new council President said.
This has been a burning issue for many patients who would from time to time complain about not understanding what doctors, most of them Cubans, are telling them during consultation.
Dr Mitchell-Amata said the problem lies with the Medical Practitioners Act which she says needs to be modified to include a clause that a doctor seeking to be registered must be able to speak English. The council hopes to advise the Minister of Health to have the amendment made. “We should do as other jurisdictions do, and if English is not your native language then you should do a test of English… go sit the exams and when you get the results and you can show me, then we can register you,” the doctor said.
She admitted that this cannot be done tomorrow, “but I can start the process.” This was a serious issue, she said, as 90% of diagnosis is done during consultation and if there is a communication barrier then there is a problem making the diagnosis.
“I have complained about this, I have seen it, I object to it,” she said, adding that there was a case of a foreign doctor being sent to the ICU and they rejected the specialist on the grounds of poor English.
“Before you put the patient to sleep you must have that conversation – we call that history taking; if they cannot do that they cannot work there and we rejected that person because it is just too dangerous. You have to know who you are putting to sleep because you might miss something important and then you have a dead patient,” she said.
Dr Mitchell-Amata stated if the doctor is really an expert who is badly needed in Guyana and they cannot speak English then they must come with an interpreter who has to be with them at all times whilst on duty. At the GPH she said she has learnt there is an agreement that foreign doctors sign indicating they should be able to speak English, and she says if they are signing these agreements and cannot speak English then they would not be registered.
Most of the foreign doctors in Guyana are sourced from Cuba, China and India, and according to Dr Mitchell-Amata the Chinese delegation which is here now is fluent in English as they “heard us making some noise and they made sure that those they dispatch are fluent…” The Cubans, she said, have asked what it is that is needed and they have made it clear that the doctors should be fluent in English as they are aware that they have rejected doctors for this reason. In relation to the Indian doctors, she said, most of them are attached to the Balwant Singh Hospital and those she has met are fluent in English but the accent can sometimes prove a problem.
It is on her agenda for foreign doctors to give lectures at the quarterly meetings which would also help them to interact with each other.
The council is part of the Caribbean Association of Medical Councils and together it is hoped that they would develop a regional standard so that any doctor who trains in the Caribbean would emerge with the same standard. In the pipeline is a regional licensing examination, and it is hoped that all the medical schools in the region would be vetted and accredited because there are many offshore medical schools.
A trained Caricom accredited inspector, Dr Mitchell-Amata will be taking a closer look at the schools in Guyana of which there are five: University of Guyana (UG), American International School of Medicine, Texila American University, Greenheart Medical School and another. While UG has its external inspector she said the other schools need to be inspected.
On the Caribbean level as well, Dr Mitchell-Amata said that they are working on ensuring that foreign specialists who practise in our countries should not just earn and leave but also help to train local practitioners.
“…one of the things I really want to do, and it ties into the whole thing of improving competency… every single doctor as soon as [they] graduate from medical school [should go] straight into postgrad training so any patient is either being seen by a specialist or a specialist in training.” She knows a problem will be encountered with the Ministry of Public Service which has regulations that stipulate that government trained doctors must serve for five years before they can further their studies.
“That five-year bond is a coffin with nails, because [just after graduating] is the time to specialize not to sit down for five years…” Dr Mitchell-Aamata said, conceding that the “problem is bigger than me” as “far more senior and powerful” members of the medical community than she is have tried working on this issue in the past.
She said the answer is always ‘when you train them they leave,’ but she strongly recommends that they be trained during that five-year period because “during the time they are being trained the public is getting treatment from persons who are reading and who know what they are doing.” She pointed out that the doctors are not competent when they leave medical school and that is why they need to work under supervision, which needs to be stringent and the supervisor must document what the doctors do.
She recalled that when former Minister of Health Dr Leslie Ramsammy had spoken to them about the specialist hospital that is expected to be set up in Guyana, he had said when asked that one of the goals was to train young doctors. While she has not heard anything since, she hopes that the various degrees would become part of UG’s curriculum and any specialist that comes to work in Guyana will not just practise but be part of the teaching faculty to train young doctors.
She said the Chief Medical Officer, who is a part of the council, has looked at Guyana’s needs and worked out how many specialists the country requires based on the pattern of diseases.
“If I get nothing else [during my tenure]…the language and improving the competency of doctors through specialization are my two biggies.”
It hoped that the council’s website will be updated frequently and have links to best practices and standards, as well as guidelines informing doctors that those are the standards by which they will be judged.
She hopes that the council would help to educate patients on their rights, which include their right to ask questions and not just be passive objects and have tablets thrown at them. She also keeps advocating for doctors to form themselves into an association since the council does not represent doctors.
The rotation of newly graduated general medical practitioners needs to looked at and Dr Mitchell-Amata said that the system that obtains at the GPH needs to implemented nationwide. This would entail the newly graduated doctors completing various tasks in the medical system before they can be registered.
“What we are saying is that when you come back, it is not a matter of staying or working at a hospital or health centre for eighteen months… during those eighteen months you must have done so many things… so when we are registering you we have objective evidence to show that you have certain competency and skills,” she said.
‘No testicular fortitude’
Meanwhile, Dr Mitchell-Amata said she is aware of the criticisms levelled at the council and she sums it up as being accused of having “no testicular fortitude,” although she admits that they experience difficulties with investigating cases. She gave one example of receiving a complaint at the beginning of the year requesting information which was not sent until October 5.
According to her private doctors respond almost immediately, but not the public system, and she wondered how the council could compel a hospital to respond promptly and what the penalty was if they didn’t.
“There has to be something, so that is one of the things I want to discuss at our first meeting – how we can compel,” she said, adding that most of the time the private doctors turn up with their attorneys.
In an effort to speed things up the council had set up its disciplinary committee, but this actually slowed things down as the committee is headed by the Chief Magistrate “and so we are doing things really according to the court system…” While this ensures that due process is adhered to sometimes issues can be dragged out for weeks or months. She said she is working on ensuring that all documents are received when a complaint is received before the disciplinary process commences, so as to not have the matters drag on.
“We have been doing things and things have been done quietly,” she said, revealing in one instance they had asked for information from a doctor in charge when an incident occurred and that person resigned and the matter is still ongoing.
They have written letters of caution to doctors and there is one doctor who was suspended as he is not fighting the issue in the country; there is also one who was struck off the register. But when this has been done the council cannot “police” the doctors to verify that they are not working; it is an issue for the Guyana Police Force.
But she noted that the council has had cases overturned in the courts because due process was not adhered to, so this is one reason why they want to make certain that the rules are followed.
During the life of the last council, two doctors left the country while matters were being investigated; some doctors did not get their gratuity; one resigned and one migrated, “so things have been happening.” There was one case where it appeared that the complainant was seeking to extort money from the doctor, while in another, after seeking advice from two specialists in the field it could not be concluded that what had happened was a result of the doctor’s action.
Asked if the council seeks out persons on hearing about suspected medical malpractice or misconduct, Dr Mitchell-Amata responded in the negative, revealing that it was an issue discussed in the past and it was made clear that only matters that came in the form of a complaint to the council would be investigated.
Dr Mitchell-Amata, a mother of three, did her undergraduate training at the University of the West Indies in Jamaica where she also specialized, and then she moved to the UK for a while before returning to Guyana in 1996. During that period she worked at the GPH for two years as a consultant, but returned to Jamaica as she could not “cope at that time… [with] the contrast between medicine in the UK and in Guyana.”
“The part that got to me is that every day there was a patient who died who didn’t have to die, and I couldn’t cope with it so I left.”
She returned to Jamaica where she practised and lectured for a few years, but later got married and “followed my husband around the world” to Trinidad, China, US and Kenya, where she completed her Master’s in Public Health through distance education at the University of London because she had a problem “with sitting down as a housewife; my brain was fossilizing.”
When she came to Guyana in 1996 she was with two other trained anaesthetists, and together they developed a training programme to train anaesthetist nurses. After it was approved they trained two batches before she left. It was in 2007 she learnt through one of the doctors that the postgraduate programme for anaesthetist doctors they had been trying to have implemented since 1996 was becoming a reality, and this inspired her to return, so she has been in at the hospital ever since practising and training doctors. She said there have been a lot of positive changes between 1996 and the present.