31.1 The Physician as Administrative Manager: Communication and Interpersonal Skills, Teamwork, Adult Learning, Occupational Health (RA 11058), Bioethics, Palliative Care, School Health, Organ Transplantation and Birth and Death Certificates

Why this area matters

The TOS administrative manager competencies are to:

• summarize the principles of effective communication;
• recognize occupational health problems in an industry;
• apply bioethics;
• create school health programs;
• fill up birth and death certificates with proper terminology;
• counsel patients about organ transplantation.

Municipal health officers and hospital physicians manage teams, programs and records as well as patients, and errors in certificates distort the national health statistics.

Communication, interpersonal relationships and teamwork

• Effective communication:
  • active listening;
  • open-ended questions;
  • empathy;
  • plain language without jargon;
  • checking understanding (teach-back);
  • respecting the patient's language and culture, and using interpreters when needed.
• Breaking bad news (SPIKES):
  • Setting: privacy;
  • Perception: what the patient knows;
  • Invitation: how much the patient wants to know;
  • Knowledge: give the information in small chunks;
  • Emotions: respond with empathy;
  • Strategy and summary.
• Interpersonal relationships: mutual respect, trust, conflict resolution through dialogue, and clear roles. Professional boundaries with patients are maintained.
• The multidisciplinary approach: physicians, nurses, midwives, nutritionists, pharmacists, social workers, therapists and community workers plan care together. This is essential in TB programs, maternal care, malnutrition, rehabilitation and palliative care.
• Principles of adult learning (Knowles' andragogy): adults learn best when learning is:
  • self-directed;
  • built on experience;
  • relevant to immediate problems;
  • problem-centered;
  • internally motivated.
  • Training of health workers and patient education use case-based and participatory methods.

Occupational health

• Hazards:
  • physical: noise, heat, vibration, radiation;
  • chemical: dusts, solvents, metals, pesticides;
  • biological: TB, hepatitis B, leptospirosis, needlesticks;
  • ergonomic: lifting, repetitive motion, poor posture;
  • psychosocial: stress, shift work, violence.
• Hierarchy of controls, from most to least effective:
  1. elimination;
  2. substitution;
  3. engineering controls (ventilation, enclosure, guards);
  4. administrative controls (rotation, training, procedures);
  5. personal protective equipment.
• Occupational diseases:

• The OSH law (RA 11058, 2018):
  • employers must provide a safe workplace;
  • a safety and health program;
  • safety officers and occupational health personnel (first-aiders, nurses, physicians) according to workforce size and risk;
  • OSH training;
  • free PPE;
  • reporting of accidents and illnesses;
  • workers may refuse unsafe work without retaliation.
• The occupational physician conducts pre-employment, periodic and return-to-work examinations, monitors exposures and certifies work-related illness for Employees' Compensation benefits.

Bioethics in practice

The principles of bioethics are:

• autonomy: informed consent, confidentiality, truth-telling;
• beneficence;
• non-maleficence;
• justice: fair allocation of scarce resources.

These are covered in Legal Medicine. In public health, they are balanced with the common good, for example in mandatory reporting, quarantine and outbreak control, using the least restrictive effective measures.

Palliative and hospice care

• Palliative care improves the quality of life of patients and families facing life-threatening illness. It begins early alongside disease treatment, not only at the end of life.
• Hospice care is palliative care in the last months of life, at home or in a facility.
• The WHO analgesic ladder:
  • step 1: non-opioids (paracetamol, NSAIDs);
  • step 2: weak opioids;
  • step 3: strong opioids (morphine);
  • plus adjuvants (antidepressants and anticonvulsants for neuropathic pain, steroids);
  • give "by the mouth, by the clock".
• Other symptoms to manage: dyspnea, nausea, constipation (always give a laxative with opioids), delirium and psychological and spiritual distress.
• Advance care planning records the patient's wishes.
• The National Integrated Cancer Control Act (RA 11215) includes palliative care and access to pain medicines.

School health services

• The school health program of DepEd with the DOH and LGUs covers:
  • health services: examinations, vision and hearing screening, immunization in Grades 1 and 7 and HPV vaccine for girls, deworming, oral health;
  • healthful school living: safe buildings, water, toilets, and WASH in Schools;
  • health education (including sexuality and substance use);
  • the school-based feeding program (RA 11037);
  • mental health and anti-bullying policies.
• The school physician or nurse keeps health records, identifies children with illness or disability, and coordinates referrals and outbreak control in schools, such as for measles, influenza, dengue and food poisoning.

Basic principles of organ transplantation

• The Organ Donation Act (RA 7170, 1991):
  • allows any person of sound mind aged 18 or older to donate organs after death, by legacy (will, donor card or driver's license);
  • in the absence of a legacy, the next of kin may donate in a specified order of priority.
• Brain death:
  • irreversible cessation of all functions of the brain, including the brainstem;
  • determined by the attending and consulting physicians;
  • physicians of the transplant team do not take part in declaring death.
• Living donation:
  • must be voluntary, informed and free of coercion;
  • commercial sale of organs is prohibited, and only legitimate expenses may be covered;
  • living non-related donation needs ethics committee review under DOH rules.
• Counseling covers risks to living donors, the need for tissue matching, lifelong immunosuppression for recipients, and the family's role in deceased donation.

Birth and death certificates

• Certificate of live birth:
  • registered with the local civil registrar within 30 days;
  • signed by the attendant;
  • data include the name, sex, date and place of birth, birth weight, the type of attendant and the parents' details;
  • delayed registration needs supporting documents.
• Certificate of death:
  • the attending physician certifies the cause of death;
  • it is submitted to the local civil registrar within 48 hours (PD 856);
  • deaths from violence or suspected crime are referred to medicolegal authorities.
• Recording the cause of death (WHO format):
  • Part I is the causal chain:
    • (a) immediate cause, the final disease or condition;
    • (b) and (c) the antecedent causes;
    • the underlying cause, the disease that started the chain, goes on the lowest line used;
  • Part II lists other significant conditions that contributed but are not in the chain;
  • give an approximate interval from onset to death.
• Common errors:
  • writing modes of dying ("cardiac arrest", "cardiorespiratory arrest", "respiratory failure") without a cause;
  • abbreviations;
  • more than one cause on a line;
  • illegibility.
  • The underlying cause is what national statistics count, so accuracy guides health planning.
• Example:
  • (a) hypovolemic shock;
  • (b) upper GI bleeding;
  • (c) ruptured esophageal varices;
  • (d) alcoholic liver cirrhosis.