ON DOCTORING.
Posted by bmhegde on 1
Medical Education:
Should I say how badly does the present medical education needs drastic changes to be socially relevant? A recent UNIDO report showed that more than 80% of the world's population even now does not have any touch with modern medicine of the type that we teach and practice. Their needs are only three.
*Clean drinking water
*Three square meals a day uncontaminated by human and/or animal excreta, and
*Economic empowerment to avoid the deadliest stress of not knowing where your next meal comes from.
All the improvement in human health has come from economic and sanitary improvement in human dwellings and not from the hi-tech medicine that is being touted as the panacea for all human ills. There is nothing like a pill for every ill. Medicine "cures rarely, comforts mostly but consoles always."
To that end in view we must restructure medical education to produce human and humane doctors that understand the agony and pain of the suffering human beings to give succour to them. Present education throws up mostly good technicians that are good in "interventional medical techniques" but are bad, many a time, in dealing with suffering humanity.
The pinch is felt by many in the filed and one University, the Brisbane University in Australia, tries to pick medical students from among the graduates in humanities-arts, literature, music etc. Their experience has shown that this class of students would make better doctors; while the physics, chemistry and biology students make better technicians.
Two important areas need clarification to our students and doctors. One is that health of the public (public health) does not so much depend on medical quick-fix methods as it does on social changes in hygiene, food, and environmental factors. Let us keep these two on different pedestals, although both are needed for society. The other message is that life expectancy is only a statistical term denoting the number of years a newborn child could expect to live. It has nothing to do with life span at all. Many of us have this misconception that modern medicine has increased our life span. Far from it, very, very far. The truth is that modern medicine, if anything, has decreased our life span with many of the newer inventions and interventions!
Qualities of Head and Heart:
A good doctor should be able to combine the qualities of the head and heart to be able to do most good to most people most of the time. On the bedside, even an illiterate patient very astutely studies the body language of the doctor. The patients and their relatives are always anxious when they are ill and they expect their doctor to be good, brave, efficient and kind all at once. To be able to discharge one's duties as a good doctor, one should be able to combine the qualities of a strong head that could take difficult decisions even under very stressful situations, and the kindness of a large heart that has an insight into human suffering. The two key words that every young doctor should remember and revere are imperturbability and equanimity. Every word and action, including the mannerisms, are being watched carefully on the bedside by the sick individuals and, as such, they should be impeccable. Humility should be the watchword as uncertainty is the only certainty in medicine.
" Of the terrible doubt of appearances,
Of the uncertainty after all-
That we may be deluded…."
Walt Whitman.
Mistakes:
Another area that needs clarification is in not telling our students in the college that doctors, like other human beings, are fallible. We are liable to make mistakes and that has to be made known to our patients, lest they should get the impression that doctors are Gods that never make mistakes. Now that we have given that impression and deified ourselves, any small mistake that we commit attracts lawsuits for compensation. This American disease is coming to India in big way and that would make medical care very expensive. Would you be surprised to know that in the USA more than 62% of upper middle class Americans cannot afford health insurance as the premia are very high, based on the star-performers' charges?
Medical education must aim at training the future doctors in accepting the fact that human beings, doctors being human beings, make mistakes. The relatives and the patients would certainly understand and condone any genuine mistake done during a doctor discharging his/her duties. We must train students to develop to accept mistakes honestly and discuss the same plainly and in every detail with the patients and the relatives. Proper communication skills before and after treating a patient would enhance a better doctor-patient relationship, which has received severe beating in the last couple of decades where technology hijacked the time-honored humane bedside medicine. Time was when doctors were very highly respected in society. Today doctors are a suspected lot in society as greedy, self centered, and avaricious.
This has attracted the menace of consumerism into medicine. It is the medical profession that took medicine to the market place as a business, attracting the legal clause that medical care is a saleable commodity and the patient is a buyer. With this new equation today judges perceive every suit filed against doctors seriously. To reverse this trend we must train our future doctors to be more humane and authentic.
Medical Science:
The European universities accepted medicine as a scientific discipline around the beginning of the 12th century along with other natural sciences. However, the surgical specialties still remained outside the purview of the physicians; the former were still considered as skilled barber-surgeons. It was only in the 16th century with the advent of the Royal College of Surgeons in England that surgery was also included among medical sciences.
However, it is very important for a budding physician to realize that medicine is first and foremost an art, based on scientific principles. “Art” said Henry Edward Thoreau, “is that which makes the man's day.” The art of medicine is that which makes the patient's day – improves the quality of his life. It was Hippocrates who wrote, around the first century BC, that physicians “cure rarely, comfort mostly, but console always.” This holds good even today. Most of what we do to our patients is to relieve pain and suffering. Whether doctors have the capacity to extend lifespan and to prevent death is a moot question.
Philosophically death is the only certainty in life. Preventing death is against the natural laws, but alleviating pain, suffering and disability, should be our motto. To do that, doctors must learn “to do unto others what you would be done by”. Empathy, where the doctor puts himself in the patient's shoes, should be the hallmark of the character development of any young doctor. It is only when we learn to empathize do we really become placebo doctors. Unfortunately, today’s medical education produces doctors trained more as hi-tech technicians and not as holistic healers.
A healer needs a kind and a compassionate heart. Emotions do have a part to play in patient care; patient care being just CARING for the patient. Said Gautama Budha “ a doctor should look upon his patients just as the mother looks upon the child, her only child, bestowing all her love and attention on the child.” Medical humanism should be a special subject for training doctors in medical schools. Technology and skill should only be added assets to a doctor but the core of every doctor should be his qualities of head with love, compassion, caring and sharing.
The Future of medical science, nay-other natural science, is in the capacity of these sciences to come together and understand one another, but not in getting further fragmented to the detriment of looking at the patient as a whole. The human body does not function in an organ-based isolation. The body works as a compact whole and not as a combination of its bits, working in different levels and directions. In addition, the human organism exists on this planet in symbiosis with all other living organisms of which there are billions and trillions around us.
Modern medicine followed natural sciences and their mathematical rules of linear systems. Although, physics, the king of sciences, left this narrow path a couple of decades ago after the advent of quantum physics, which has shown the futility of pursuing linear mathematical rules. Quantum physics has thrown up the existence of the human consciousness, which alone could gauge and assess the depths of this wonder, our Universe! Medical sciences did not follow suit; we continued our research efforts using reductionist methods.
Lately, lot of well designed randomized studies both in the USA and UK have shown the vital role played by the human mind and emotions in bringing about the incidence and ravages of the leading major killers like cancer, heart attack, stroke and even minor illness syndromes. These are mainly brought on by human emotions, rather than the conventional risk factors like cholesterol etc. Scientists, both in the medical field and outside, especially in quantum physics, have realized that one cannot work and understand the working of this universe, man included, without the help of the human mind.
Where is the mind? Never mind! This simple answer would no longer hold water. The human mind is not an organ based cyto-pathological structure, it is in the realm of the sub-atomic quantum field in every single human body cell, of which there are one hundred thousand billion in all. Werner Heisenberg’s Uncertainty Principle and Erwin Schrondinger’s Cat Hypothesis have shown, very clearly, that excluding human mind would not solve problems. I hope thinking people would now believe that time has come to have a re look at medical education doled out in our schools which, probably, would bring out excellent medical technicians skilled in interventions, but do not bring out humane healers.
Continuing Professional Development:
"Half of what man knows today would be proved wrong in five years' time, but the problem with mankind is that they would not know which half it is." wrote Cicero, the great Roman thinker. This is truer in medicine where, on an average, 35,000 new publications come out every month in the innumerable bio-medical journals mushrooming all over. One needs to keep in touch to be able to deliver the correct line of management every time a patient seeks advice. Mandatory re-certification is being thought of, but it is imperative that every doctor keeps himself up-to-date with his specialty always, in addition to self learning from one's mistakes. The latter is very precious empirical experience that helps in patient care.
Research:
Research is an integral part of teaching. The greatest research in the past has been the observational research of our ancestors. Although, we have produced a surfeit of research data with more than 35,000 research papers coming out every month in the innumerable bio-medical journals, a recent audit showed that less than 1% of it is making any mark in advancing human wisdom. Future research must concentrate on the need-based, locally relevant, problem solving questions rather than replicating what the advanced west does, to publish or perish. Repetitive research does not widen our horizon. There are innumerable myths in medicine, which need to be demolished. The quicker we do it the better for the suffering humanity.
"Knowledge advances NOT by repeating known facts,
But by refuting false dogmas."
Karl Popper.
A recent UNIDO report showed how the modern hi-tech medicine did not reach the majority of suffering human beings in the world who, still lack the basic amenities of life like clean water, two square meals a day and a healthy environment to live in. Poverty, still is the largest risk factor for disease. In addition, it is a double-edged sword. While poverty brings on more illness, the resulting illness deprives the hapless victim of his earning capacity. It thus cuts both ways. Economic empowerment of the masses and alleviation of poverty are as vital to reduce the disease load in society, as it is to palliate the existing diseases.
As modern medicine quick fixes are absolutely necessary in emergency situations, many of the chronic illnesses and minor illness syndromes either do not benefit from the top heavy modern medical establishment, or could do well with very inexpensive but effective alternative of systems of medicine, of which there are many in our country. Whereas it is mandatory that we teach our students the usefulness and the existence of these systems as also the public dependence on them, we must work fast to sift the wheat from the chaff in all those systems, by using the touchstone of modern scientific methodology. Here again, having a holier-than-thou approach has been counter productive. We should be able to take our holistic approach forwards with the help of the other systems and not by having an ostrich like attitude in condemning the latter.
In conclusion, let me wish all the young entrants into the noble profession, God speed and good luck. May they be enthused to commit themselves to public health, the health of the public. Let them be very clear in their mind that the profession of medicine is not for making money primarily, although money would automatically come, but to keep society as healthy as is humanly possible. I hope the new budding physicians would have the continued patronage and support of their teachers and parents in their journey to help society. I wish to congratulate the staff of this institution who have made it possible for all these young men and women to be where they are today. May God be with all of us.
"To handle yourself use your head,
To handle others, use your heart."
Anon.