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Bangladesh-2011 288“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.

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“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.

11 Responses to “Medical professionalism: The missing link that can save the day”

  1. rickta

    This is a story of girl who lost her only one most loved brother in last September.. I am not here to say doctor’s fault but I am here to tell you how they treat my brother on his last day of this earth. I still get nightmare! I still recall that when my boy friend here In London is a GP and offered to talk to BD’s doctor to get update since they were giving different information each in hours! But their complet refusal made us vulnerable to help my brother for last moment! And when i could flown from London to Bangladesh within one day… whereas my relatatives couldn’t get released from the private clinic, couldn’t get ambulance that can bring him to capital! And my brother died on the way!
    I don’t think anybody else could build my trust anymore about BD’s medical system! Doctors are there free from accountability! Above any law! That’s all I can say…my heart crys!& will cry rest of my life!

  2. Anwar A. Khan

    Dr. Zaman : I can proudly mention the name of a humanist doctor in Dhaka. He is Dr. Dr. Bernard B. Nath, MD (Italy) (Rogmukti Paharmacy, 22, Indira Road, 1st Floor, Firmgate, Dhaka-1215), a very kind-hearted Doctor of medicine by profession. He has been treating his patients since long, say for more than 35 years, with strong dedication, medical skills and kindness; he always remain concerned with promoting, maintaining or restoring human health through his excellent treatment. He takes a very nominal fee of Tk.50.- only per head/consultation whereas he can easily take Tk.500-600.- but he does not do that. Every patient is a true votary of him. He is a perfect Doctor, perfect in all respects and a perfect human-being. Innumerable patients have been taking his quality treatment with great satisfaction. Everyone respects him highly. Similar way, he respects his patients. But he always keeps a very low profile.

    Love live Dr. Dr. Bernard B. Nath.

      • Anwar A. Khan

        One has to need a binocular to find out another doctor like Dr. Bernard because he can be considered as a rare species of doctor in our present times. All doctors in Bangladesh should learn from him what exactly will be a doctor’s role to a patient.

  3. Naureen Shihab Amrin

    Mr. Mohammad Zaman,

    I thank you very much for writing such a nice piece.

    I believe a doctor should have the following attributes (which we found in our doctors in those past golden years, 30-40 years back in our country but now-a-days we can’t even think of getting a doctor with such qualities) :

    Treat patients as individuals and respect their dignity; treat patients politely and considerately; work in partnership with patients; listen to, and respond to, their concerns and preferences; give patients the information they want or need in a way they can understand; respect patients’ right to reach decisions with him about their treatment and care; support patients in caring for themselves to improve and maintain their health; maintaining trust; be honest and open and act with integrity; and never abuse his patients’ trust in him or the public’s trust in the profession. And he is personally accountable for his professional practice and must always be prepared to justify his decisions and actions.

    We now want to get the culture of those qualitative doctors back in the country. Will it be wrong if we, the common people, want that?

  4. Adnan Bakir

    Doctors responsibility is way more than any others. They must be above petty thinking.

  5. Anwar A. Khan

    Dr. Zaman :

    When we go to any doctor we show our full respect to them. They are the most priviledged persons in our society. Patients must be able to trust doctors with their lives and health. To justify that trust doctors must show respect for human life and make sure their practice meets the standards expected of their domains. But as ill luck would have it, the vast majority of our doctors do not, at all, act like doctors; they are not punctual in attending to their chambers; they do not give a full hearing of patient’s complications; they advise to go for so many medical tests; they run after money only; they make patients hostages according to their whims. So, look at their attitudes towards the patients! Who will accept this kind of sorry state of our doctors?

    Your article is an extraordinarily great! I am overwhelmed to have read it. You are a doctor and you have correctly depicted how a doctor should really be. You have internalised those rare qualities in your soul because you believe them whole-heartedly, hold them without pretense, think about them deeply and act accordingly while you treat any patients; and maybe, because of those reasons, you have presented certain truths so courageously in times of so much moral degradation in every sphere of our lives.

    Thank you, doctor; you should receive our laudatory reception. God bless you.

    • mzamanmd

      David B. Acker
      Apr 27 (1 day ago)

      to me
      An insightful and refreshing perspective on the essence of healing. It’s wellspring is mutual respect and humility. Irrespective of one’s role in the care of patients (nurse, administrator, ward clerk, physician), properly approached, we must perform those functions with the understanding that we are servants engaged in the cause of healing humankind.

      It is the absence of hubris, the disregard of false constructs of hierarchical importance, and that humility of which you speak that allows for the best system of care. It is an honor to be asked by patients to be that servant. When approached from that anchoring principle, it rewards those servants by opening a door through which our most selfless and noble work may be done.

      Dear Mr. Khan,

      I looked at the problem from as physician living in North America, where a physician, even if not idealist, has to be accountable by law. In this country, we also are blessed with a system, where, honesty and moral practice is usually rewarded. The aforementioned note is from my superior, who runs my hospital; just compare his thought process with that of a public hospital chief in Bangladesh – usually a military transplant with no knowledge of health care administration. You can not expect good delivery of care even from the best of doctors, if they are not in the right milieu.

      I still think, the onus is on US – the doctors to raise our voice to change the system as dictated by the third principle.

      We have lot to do and a long way to go. I have faith in my dear friends in Bangladesh. The best students of my batch are still in BD – they all are wonderful doctors and work much harder than me …

      • Mohsin Reza

        Dr. Mohammad Zaman,

        Your write-up is an excellent one for which I thank you very much. A doctor should be like that as you have presented in the article. But I don’t think you are correct when you say there are wonderful doctors in Bangladesh and work much harder than you. In fact, their attitudes are anti patients. Instead of giving services, they give dis-services to their patients causing further damages and financial losses.

        Secondly, your comment sounds that you have tried to glorify the doctors’ group of people burying the truth.

      • mzamanmd

        In general you are right. There is a ugly permeation of greed and hubris in the entire system and I have no qualms about admitting this truth.

        But I know my friends, many of whom are now leaders in the community, from a very close quarter. I see them as decent individuals and decent doctors, however, without a decent working environment.

        Not long ago, when I was talking to a friend of mine (a surgeon of repute), he lamented that, junior doctors both by rank and knowledge/experience, often dictates their schedule, for they belong to a certain political “Ghorana”.

        Things are not that simple …

  6. Minarul Alim

    Yes doctors need to realize their profession is not an ordinary one but very special and humane. They cannot act like ruffians as they did in a few recent events.

    So must realize the general people how noble a doctor’s profession is. People must treat them with respect.

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