(MIS) TRUST.
Posted by bmhegde on 1
“The world is a dangerous place to live-not because of the people who are evil but because of the people who don’t do anything about it.”
…Albert Einstein.
Confucius told his disciple, Tsze-Kung, that there are three vital things for any King or Government: food, weapons, and trust. If all three are not available at a given time, the King could first spare weapons and then food. Trust should be the sheet anchor of any system. He said: “without trust we can not stand.” I think he was right. Recently, when the foot soldiers of Saddam Hussein lost trust in him they deserted. Food shortage need not necessarily topple any government. Second World War is an example. India had severe food shortage but we accepted the strict rationing and still supported the King! The sad events of 9/11 showed that the enemy could strike and destroy without the sophisticated weapons at their command compared to the American army. When the king loses trust of his people, he would soon lose his grip on the empire! Dame Onora O’Neill, in her Reith Lecture series 2002 for the BBC, gave a graphic account of how “complete absence of trust would prevent us from even getting up in the morning.”1
Modern medicine is at the crossroads today. Hospitals are empty, patients angry, doctors frustrated, HMOs in the US are declaring chapter eleven by the day and there seems to be confusion all round. NHS patients in the UK have to wait for months to get routine surgeries done. These days doctors do not get enough time for even talking to their patients. Technology has made medicine prohibitively expensive. Modern medicine is beyond the reach of more than eighty per cent of the world population. We doctors have a holier-than-thou attitude towards many effective methods of disease palliation in other complementary systems of medicine.2 Their practitioners carry on unconcerned and the annual herbal drug market alone is more than $ 70 billion!
If Confucius were to be alive today he would have given guidelines to doctors also on the same lines like the ones he gave to Kings. He would have listed the following three as vital for medical practice:
* Medical humanism
* Medical science of the right variety-holistic and not reductionist.
* Patients’ trust in their doctors.
Here again he would have said that the last is the most important, although the other two are as vital to the core of medicine-medical consultation, as the third. When a man/woman who is ill or imagines he/she is ill, comes to seek the advice of another man/woman in whom he/she has confidence, the meeting of two minds is called medical consultation. This is the heart of patient satisfaction and this helps in no small measure in the eventual patient recovery. Even the best surgeon, many of them do not get time to see their patients in the waking state hopping from one theatre to another without any break, could only cut and suture but the healing or non-healing depends on the patient’s immune system. The latter is mainly under the control of the human mind.3 Patient satisfaction, therefore, is as important for recovery, as are the drugs, technology, the surgeon, and the array of scopes and scanners. This is one of the reasons why many practitioners of complementary medicine score over us. They practice empathy in addition to their skills and have more time to spare for each patient thereby stimulating the patient’s immune system.
Bad News:
Modern medical methods and their practitioners have been shown in bad light by many skeletons stumbling out of their cupboards lately. Doctors went on strike in Israel for three months in the year 2000. They attended to emergencies, though.
Death rate and disabilities were reduced dramatically during those months only to reach their original levels soon after the doctors came back to work.4 Routine screening has been one of the biggest money spinners for the profession and the instrument manufacturers, but has been a curse on the healthy population.5 The divine interventionalists have been having hey day making money and earning fame and respectability but all their efforts have been misdirected, since time evolution in a dynamic system is not linear. Most of the drugs used to correct the presumed abnormalities like raised blood pressure, sugar, cholesterol and many others in the apparently healthy people have not had the desired results in the long run.6 To give a simple example: eight hundred and fifty healthy people would have to take blood pressure lowering drugs for a period of five long years to save probably one person with mild-moderate hypertension from stroke in the next five years!7 One could also imagine the unimaginable side effects of those drugs in those hapless people who agree to take drugs hoping to get direct benefit for themselves. One in four drugs prescribed for any ailment in the normal course would result in serious side effects, many times necessitating hospitalisation.8 Epidemiology, applied to non-communicable diseases, makes the false positives go up exponentially. Disease statistics when applied to healthy population distort the outcomes making life miserable for those who opt to come to modern medical treatment.9 Statistics apply only to large cohorts of men or women but they have no relevance to the individual patient sitting in the doctor’s office. A clever statistician could even make his tool work for him. Mushrooming of risk factor studies came out of large research grants for such studies in the post-Second World War period. Hospitals have been closed because of the misuse and overuse of inappropriate technology.10 Drug manufacturers were caught inventing diseases to sell their wares.11 Money has been an attraction even to fake research. People have not hesitated to invent newer viral causes for diseases basically to sell drugs or get fame.12
Need for a paradigm shift in medical philosophy:
Human activities are guided in society by the common philosophic outlook. The western materialistic mindset has eroded the altruistic medical ethics of Hippocrates and his followers in Greece. Doctors are trained not to make money but to look after the health of the public. This laudable motto has long been forgotten and medicine was taken to the market place, where all the market forces started working on it. Today in the west, medicine is a commodity: the doctor the seller and the patient a buyer. Immanuel Kant, one of the great brains in the west, had classified the western mindset into two different classes: happy but not good and good might not be happy. Today doctors are happy by and large but I doubt if they are good on Kant’s terms. Kant thought that people should be good even when their own happiness is at stake.13 Owen, quoted by Daniel Goleman, in his interesting book Destructive Emotions, tries to put the western mindset into three water tight compartments thus:
* Rational egoists
* Selfish and compassionate
* Compassionate and selfish
The first live totally for themselves and are rational to the core. The second are very selfish, but when there is plenty to waste they might think of others. The last are compassionate in the sense that when there is plenty they would like to share it with others, but under special conditions of scarcity of any commodity, they only think of their needs and forget others. A very comprehensive picture of the western mind set, indeed. The east is different. Buddhism teaches what they call tseva (service) as the motto of life. This is service above self philosophy. Goutam Buddha did record that a doctor is like a mother to every patient. The mother, especially the one with only one child, showering all her compassion and love on the child. Doctor, he felt, should do the same. The Indian timeless Vedic wisdom does propagate the dictum that a human being is born here primarily for the good of others in society-societal dharma, the obligation to society-the rent one pays for the parking lot here on earth.
Medical fraternity would do well to change from the totally materialistic mindset to that of a new philosophy in between the eastern and the western ones. It may be difficult to follow the east in its totality in the present world of cutthroat competition. One could choose to be compassionate and selfish and try to intervene only when the patient needs help. “Patient doing well do not interfere” was the Oslerian dictum, which is true even today. Interfering in the asymptomatic stage of any incubating disease might interfere with body’s efforts to correct the damage.
What role does patient trust play in healing?
Recent advances in psycho-neuro-immunology have opened up a new vista of knowledge that gives us an insight into the human mind. Gone are the days when the answer to the million dollars question: “where is the mind?” was “never mind”. Quantum physics has thrown new light, which the eastern wisdom had shown thousands of years ago, that the mind resides in every cell at the sub-atomic level and is connected to the universal consciousness of which each individual is an indivisible part. With this background, scientific studies of even intercessory prayer were shown to help in the treatment of acute myocardial infarction, as an important adjunct.14 Placebo effect is nothing but this immune stimulation. Patient trust in the doctor, therefore, is the centre of attraction for healing. Nocebo doctors, doctors that do not have time for their patients to get an insight into patient problems, naturally do not command patient trust. Patient care is caring for the patient. Patient’s emotions do play a vital role in the aetiology of diseases. Destructive emotions like hatred, anger, jealousy, and depression play an important role. Young medical students, studied prospectively with PET scanners, did show a strong relationship between early coronary calcium deposits and hostility scores! To understand all that and to undo the damage, the doctor has not only to intervene with angioplasty and/or CABG, but also by helping the patient to replace his destructive emotions with positive thinking.15 Then, and then only, would doctors earn patient’s trust, which assists the final healing, reversing the damage inside the vessel wall. In the normal intervention the patient improvement is only temporary, recurrence waits round the corner. The physician should have a healer’s heart and a career’s hands.
“Civilization is just a slow process of learning to be kind.”
..Charles L. Lucas
Bibiliography
1. O'Neill O. Reith Lectures 2002. www.bbc.com
2. Weil A. The significance of integrative medicine for the future of medical education. Am. J. Med 2000; 108: 441-443
3. Frawley D. Ayurveda and the Mind 2000, Motilal Banarsidas Publishers Pvt. Ltd. Delhi.
4. Siegel - Itzkovich J. Doctors' strike in Israel may be good for health. BMJ 2000; 320: 1561.
5. Smith R. The Screening Industry. BMJ 2003; 326 : 893
6. Goddijn PPM, Bilo HJG, Feskens EJM et. Al. Longitudinal Study of Glycaemic Control. Diabet. Med 1999; 16: 23-30
7. MRC Working Party. MRC trial of mild hypertension: Principal results. BMJ 1985 ; 291 : 97 -104
8. Bales D, Cullen DJ, Baird N. et.al. Incidence of ADR & Potential Adverse drug events. JAMA 1995;274: 29-34
9. Stewart Brown S & Farmer A: Screening could seriously damage your health. BMJ 1997: 314: 533
10. Charatan F. Dozens of patients allege unnecessary Surgery. BMJ 2003; 326: 1055 - 56.
11. Moynihan R Health I, Henry D: Selling Diseases: The Pharma industry & disease mongering. BMJ 2002; 324: 886-91
12. Duesberg PH. Inventing the AIDS virus 1995. Regnery Publishing Inc., Washington DC.
13. Goleman D. Destructive Emotions. 2003. Bloomsbury Publications, London.
14. Harris WS, Gowda M, Kolb JW, et.al. A randomized controlled trial of the effects of remote, intercessory prayer on outcomes in patients admitted to the coronary care unit. Arch.Intern.Med 1999; 159(19): 2273-80
15. Benson H. Timeless Healing. 1996. Simon and Shuster, Sydney.