“Whenever a doctor cannot do good, he must be kept from doing harm.” Hippocrates
An unfortunate concatenation of events pitted the physicians of reputed hospitals, both private and public, against certain unhappy patients, and eventually bringing the powerful media into the fray. This, very well, may be a reflection of overall societal entropy; but physicians – supposedly the lambent light for the sick and the torpid, cannot accept their life’s mission be undone in such dissolute manner!
I am a physician and I feel the anguish. I totally understand the defensive posture on the part any physician; but, to me, that is no posture at all; physicians should have one and only one position, and that is to provide the best possible care for the sick – as Samuel Hahnemann once posited, “The physicians highest calling, his only calling, is to make sick people healthy – to heal, as it is termed.” And I bet, if we heed to this calling and provide the right care, as determined by the local standard of care, misgivings are sure to resolve in no time.
Good medical care rests on a single hinge upon which it revolves with a certain dignity and grace. And this hinge, commonly known as medical professionalism, is as ancient as the art and/or science of medicine itself. However, an international group of physicians recently inked a document – “Medical Professionalism in the New Millennium: A Physician Charter”, that consists of three principles and ten commitments. The first is the ”Principle of the Primacy of Patient Welfare”, dates back to antiquity when Hippocrates proposed his “do-no-harm” sermon. “Principle of Patient Autonomy” is the second and a rather contemporary history. “Principle of Social Justice” is the third of three principles, which calls upon the profession to promote fair distribution of healthcare resources, and as such encouraging physician to be healthcare activist. Unfortunately, many of our esteemed physicians, in their sorry heart, harbour no compunction for the sorry state of our current professionalism.
Before delving further, an elaboration as to the basic ground rule of a physician-patient-encounter is in order.
“The doctor sees all the weakness of mankind; the lawyer all the wickedness, the theologian all the stupidity” – thus goes Arthur Schopenhauer; without endorsing the latter slants, I agree with his first observation; that a patient seeks the help of a physician only when he feels that his well-being and his very life is in jeopardy, thus making him an instant weakling. A physician, by virtue of his knowledge and expertise, attains an almost demigod status. Sitting on a high seat, worthy of envy; a physician is duty-bound to forge a relationship with a fearful weakling, which is built on trust and dignity. The art of forging this very important physician-patient relationship is the essence of professionalism and it has, in addition to the triumvirate mentioned previously, a few essential facets:
1) Adequate knowledge and the humility of admitting the lack of it.
2) Understanding the emotional underpinning of even the most mundane of the symptoms by lending an empathetic ear that listens.
3) Understanding the patient’s sensitivity.
Adequate professional knowledge is a relative term, the function of which depends on multiple variables. Knowledge, in fact, is less important that the humility of admitting the lack of it, thus paving the way for a referral process. This process of timely referral can bring the necessary knowledge and expertise thus minimising the ugly consequences of lack of knowledge.
Every patient has a unique story to tell. Physical disease process is the product of a large number of both corporeal and non-corporeal processes. A physician must understand those processes in Toto; otherwise lot of illness shall remain unaddressed. Lending an empathetic ear is a first step for such endeavour.
As eluded above, the sickly (patient) is in a strategically weaker position. His (and family’s) sensitivities and privacy and every other issues must be addressed in a very deliberate and appropriate fashion.
These three factors are the building blocks of establishing a healthy professional relationship that brings to the issue of delivery of care, which by far is the least complicated issue. Standard of care in a given community depends on multiple variables including availability of medical expertise and ancillary support, both of which are not in abundance in Bangladesh. And this brings us to the issue of overseas medical treatment.
I cannot but agree that appropriate medical care for any kind of ailment is an inalienable right of a citizen. In an open market democracy, market force is the principal denominator of how and when and where the care shall be rendered. One of our Prime Ministers once travelled to New York City to have a rather less demanding knee surgery that, I bet, could have been done in Dhaka. She desired better care and she paid for it. On the other hand, about the same time, a friend of mine (a well-to-do-physician in Dhaka) decided to have a coronary stent in Dhaka. He paid, probably less than 1/15th of what the Prime Minister spent in New York. And that’s fine. I am using these two examples for pointing to a few poignancies: Firstly, patients with enough financial resources tend to go overseas even when they do not need to. Secondly, some patients with enough financial resources seek out and find appropriate care at home. The difference between these two groups resides in their attitude and understanding of the medical problem. It is true, however, that certain procedures cannot be done at all in Bangladesh for lack of appropriate ancillary support.
The physicians in Bangladesh, contrary to some voices, should never oppose the legitimate right of an ailing citizen to seek treatment of his desire. They, however, can raise the awareness that certain procedures, indeed, can be done very well in Bangladesh. If we can do all the knee surgeries, coronary catheterizations and stents, an enormous amount of money can be saved. Given the unfortunate political affiliations, Bangladesh Medical Association, I doubt, has the necessary “tool or will” to mount an awareness campaign. Private hospital and medical schools are probably better posited for such endeavour.
Lastly, I shall argue against the so-called “Professorial Hubris.” As a medical student in Sylhet Medical College I have seen many professors using their elite status as teachers in medical school, for ends other than teaching and medical care for the needy. They rather were busy tending their own mint-houses called “Chamber”. If those well-trained (mostly in Britain) physicians behaved a little more like British physicians (their teachers), our current predicament would have been much lighter.
The miasma that was brewed over decades of decadence is now out to broil us alive; patient always understands the heart of a caring caregiver – if they don’t; they are not to be blamed, for WE, THE DOCTORS are sitting on the high chair …
Physicians should learn humility; should learn to take time; should show appropriate empathy and respect for the patient; after all, a patient still is the best teacher for an astute physician. Only then the physicians should expect respect from their patients and expect to see a slowing of the ominous tide of centrifugal care.
And for our patrons (patients), I shall recite from Ovid,
“Medicine sometimes snatches away health, sometimes gives it”.
And doctors are nothing but mortal messengers of an imperfect medicine.
Dr. Mohammad Zaman is an immunologist. He writes from New York, USA.