Rony Brauman & Michèle Beck
Medical doctor, specialized in tropical medicine and epidemiology. Involved in humanitarian action since 1977, he has been on numerous missions, mainly in contexts of armed conflicts and IDP situations. President of Médecins sans Frontières from 1982 to1994, he also teaches at the Humanitarian and Conflict Response Institute (HCRI) and is a regular contributor to Alternatives Economiques. He has published several books and articles, including "Guerre humanitaires ? Mensonges et Intox" (Textuel, 2018), "La Médecine Humanitaire" (PUF, 2010), "Penser dans l'urgence" (Editions du Seuil, 2006) and "Utopies Sanitaires" (Editions Le Pommier, 2000).
Since 2006, Michèle Beck has worked with MSF in Niger, Chad, Jordan, Syria, Lybia, Ivory Coast and Haiti. In 2014, she was MSF medical team leader in Gaza.
To conclude, here is a summary of some avenues to explore that came up during the workshop but were not explored in more depth.
A. AT THE PATIENT LEVEL
Taking the patient and their perspective into account came up regularly during the workshop, both during the interviews carried out before the day and during the discussions. We want to put the patient back at the heart of our concerns. Some initiatives try to put this desire into practice, for example by allowing fathers to enter neonatal units; or by working more on the relationship of trust with mothers in nutritional programmes, where they act as home relays for the care team; or finally, by discussing treatment options with the patient. This repositioning underpins an approach to treatment focused on the patient as a person, who has social interactions, lives a certain distance from the project, has family obligations, etc. Our focus should not be on one organ or limb, but the patient as a whole, not split into different specialisms, which should help us to move away from working in silos. In the article “Treatment objectives: sharing with patients”Prescrire (July 2012). Concepts et méthodes: Objectifs des traitements : à partager avec les patients. (Page 544) Vol. 32 no. 345, the journal Prescrire offers a number of “thoughts on creating a better dialogue between carers and patients and better consideration of patients’ needs.” According to the authors, it is important to share treatment objectives with patients before any evaluation of the benefits and risks of the treatment concerned. To support this position, they refer back to the main objectives of carers and doctors, such as “cure, prevent a recurrence or subsequent complication, etc.” They then link these to non-medical objectives expressed by the patient, which may be connected to “a patient’s personal and social situation.” These objectives, for example preventing pain, appearance or sexual problems, or maintaining their income from work, will be a major concern for the patient. There is also a question of ethics, when the patient is not the main beneficiary of the treatment. The expected effects of treatment are for the indirect beneficiaries; the article gives the example of preventing carers from becoming exhausted by hospitalising the patient, even if there is no medical justification for it. Finally, the authors advocate talking to the patient to clarify all these objectives and rank them in order of importance, in order to make the best choice together.
In terms of our own practice, this prompts us to reflect on the following questions:
- What benefits does the patient expect from treatment?
In general terms, the main benefit we think about is curing the patient. But in the case of amputation, the medical aim is not to lose the patient because of gangrene or septicaemia. What benefit do the patients get? Some are ready to risk their lives, because losing an arm or leg is not acceptable to them. Hence the importance attached to obtaining surgical consent for amputation combined with information for patients, carried out by our teams working with patients following the earthquake in Port-au-Prince in 2010. Another example could be the migrants in the Balkans, for whom the benefit of passing through our OPDOut Patient Department était d’avoir un endroit en dehors de la cohue où rester quelque temps. En outre, ils pouvaient être soulagés de certains symptômes, mais sans rechercher la guérison.
- What are the objectives a patient has set for their treatment?
Again, in the case of migrants, their objective was to be able to finish their journey, while keeping their family together and not getting blocked at the border.
- Which of them do they see as the priority?
In all the conversations we have been able to have with migrants, their main objective was to keep their family together. So, if hospitalisation was necessary, it was not automatically accepted if the rest of the family was still waiting in the transit camps, afraid of losing sight of the person in hospital. For many of them, health problems were a secondary consideration and could be treated on arrival.
- Is the main beneficiary of the planned treatment the patient? If not, are they or their representatives aware of this?
These questions are typically those we should be asking ourselves in response to the Ebola epidemic, where the primary objective was to isolate contagious patients from the population, in order to reduce the spread of the disease. Similar questions also need to be asked in the context of clinical trials. These questions point to the importance of keeping not only patients but also their families informed, for example when there are children involved. Information will cover not only the patient’s situation and case management, but also therapeutic choices. The palliative care mentioned during the workshop is a good illustration of the value of dialogue with patients and their families in making therapeutic choices.
B. AT THE GROUP LEVEL: RELATIONSHIP TO STANDARDS AND ORGANISATION OF WORK
As we have seen during the workshop, issues of quality are closely linked to the way work is organised. The main problem identified in the first chapter is a decision-making process that is both confused and remote from the field. This results in a vicious circle, where the teams have the impression that they are simply operatives and disengage from the processes of reflecting and making suggestions from the field. Their sense of responsibility is removed by a priori control and by all the various validation processes, for example for cash requests or pharmacy orders. Medical advisers can block a decision even if this has been taken according to the procedure, and as a result short-circuit Operations, which creates confusion for the teams in the field.
The other problem associated with the organisation of work is the difficulty of maintaining quality as the teams are replaced, either because of turnover, gaps, handover difficulties, a somewhat fatalistic attitude among the teams or information that fails to get through to the field. In response to these problems, and as we have seen many times during the workshop, ergonomics experts advocate the right to make a mistake and above all, the analysis of these errors by those closest to the action. The environment must be supportive of these kinds of practices, and trust is the linchpin. The underlying assumption is that most people who commit to working for MSF want to produce high-quality work. Trust is the main condition for giving the teams the room for manoeuvre they need to do their work. This can be manifested by a posteriori control, which would help to give people a sense of responsibility, unlike the infantilisation produced by a priori control. Without doubt, it will result in new errors, but the aim is not to remove errors, which would be a utopian view, but to use them as the basis for collective reflection.
Not everything can be “regulated” or standardised, hence the importance of space in which the teams can “tinker”, i.e. adapt their ways of working to the context, set priorities for quality improvements, makes suggestions, etc. “Being able to cope (…) is a quality that is recognised as essential [in the humanitarian field]. It means that an expatriate who is caught up in an unusual situation is capable of reinventing and managing new situations.”Dauvin, P. & Siméant, J., (2002). Le travail humanitaire. Les acteurs des ONG, du siège au terrain. Presses de Sciences Po (P.EN.S.P.) (P.323-324)
Even so, autonomy and trust have to work within a framework in order to avoid undesirable deviations. Once again, the work of ergonomics experts and the presentations by Adélaïde Nascimento and Christine Fassert offered us insights into possible methods. Creating spaces of discussion, for example, to define acceptable and unacceptable practices seems to be an interesting avenue. Particularly as they involve conversations within the teams, i.e. encouraging dialogue between peers who are all part of the same work group. . A group that comes together around a particular topic at a specific time. A department is not a work group, but an administrative division
The importance of work groups in creating this framework has been studied by Sandrine Caroly: “The work group (…) has a protective function in terms of the individual’s subjectivity in their relationship to action. This protective function works primarily through the group’s ability to develop (…) norms and rules to frame the action, in conjunction with quality criteria for the work, to manage potential conflicts in working relationships and ultimately make the work meaningful. It allows each of its members to access this meaning and the quality criteria for “work done well”, based on a set of occupational standards. (…). The work group emerges as a resource for developing health in its broadest sense. It allows the individual to “take care” of their work and from this point of view, it contributes to individual health. Moreover, it encourages learning and skills development.”Caroly, S., Barcellini, F. (2013). Le développement de l’activité collective. In P. Falzon (Coord.) Ergonomie
Constructive (pp. 33-46), Paris, France: PUF
It is also important not to confuse team autonomy with suppressing managerial posts. Discussion groups cannot operate without the presence of a “local manager” who comes from the same professional background and understands the constraints of the job. In an article in Santé et TravailMahiou, I. (July 2010). Le management redécouvre le travail. Santé & Travail. no. 071 examining the various factors that have a positive impact on well-being at work, Matthieu Detchassahar emphasises the importance of this framework: “There has to be a discussion about the quality of the work (…). But it presupposes engineering spaces of discussion. Our research shows that health at work is better in set-ups where these sapces are well thought through and the manager is present. The problem today is less about the pressure exerted by the manager than their absence. It is no longer about regulating the work but about reporting and meetings.” The importance of local managers lies in valuing occupational skills and recognising work that is well done, but also in recognising the difficulties faced by the teams, by being there alongside them. “Ultimately, employees suffer more from a lack of management than too much of it."Detchassahar, M., Grevin, A. (2009). Un organisme de santé… malade de « gestionnite ». Annales des Mines – Gérer et comprendre (No. 9.