physician heal thyself

[J.VENKATASUBRAMANIAN]

Hello list,
The following is an article I saw in the Hindu, an Indian Newspaper
with good standards in its April 7 th, 2002 Issue. Read it.
Venkat

Doctors are not the demi-gods that they were once considered to be,
when they were able to meld together science and humane values. `Why
is the public disillusioned with their performance?' asks Dr. KAVERY
NAMBISAN, on the occasion of World Health Day today.

``Doctor, do you think I need an MRI?''

THIS from a patient whose hernia I was to operate on in a couple of
days' time. He was a business executive in Madras (as it was then
called) where I was a consultant surgeon, some five years ago. He
explained that someone had advised him to have an MRI scan before the
surgery. Why? I asked. Oh, to be doubly sure of the diagnosis. I told
him to go ahead and have the scan if it made him feel any better. It
would only cost Rs. 5,000.

I should have added that if it was a doctor who had advised him, it
would certainly make him feel better since he would get a 30 per cent
commission on the fee.

That patient was sensible enough to forget about the needless scan
but it made me think: What role do doctors actually play in keeping
us healthy? Specialisation and fragmentation of health care have
compounded the terror of falling sick: patients visit technology-
savvy hospitals and stagger out with their wallets stripped and minds
still baffled about the illness. Meanwhile, doctors whiz from one
hospital to the next, combining skill and speed with their money-
making ability. Time is money.

A friend was relating to me his recent unhappy experience at a
hospital in Bangalore. Half in jest, he added: "Doctors are as
despicable as politicians." Everyone adores money, why not the
doctors, I asked, in a feeble attempt to defend my colleagues and
take the easy way out of a pointless argument. Pointless because I
knew that there was some truth in what he said.

While introspection and an honest look at our shortcomings is the
key, it will help us to look back at how Medicine has evolved.
Doctors until recently earned trust and respect. This because they
were able to meld the Science of Medicine and the Art of Healing with
that other ingredient: Compassion.

In ancient Greece, the sick went to temples with the hope of a cure
by a ritual called incubation or "temple sleep". They were said to be
visited in their dreams by Aesculapius, God of Healing, who revealed
to them the cure. These temples were the oldest hospitals and the
inscriptions on the walls, ancient case records. Even with such
supernatural modes of therapy, common sense prevailed. Aesculapius
gave his patients sound advice on diet, baths and exercise.

Four hundred years before Christ, Hippocrates practised the power of
careful observation. He watched the way a patient moved, spoke and
sat; he listened and predicted the course of disease. He stressed the
importance of diet in the cure of illness. "Our natures are the
physicians of our diseases," he said.

Medical care in ancient Egypt was advanced: mummies have been found
which have artificial teeth and well-set fractures. Trepanning —
drilling a hole in the skull to let out the evil spirit causing
disease — was widely used. Neurosurgeons still use this principle of
decreasing the pressure within the skull by practising more
sophisticated techniques.

In India, Susruta and Caraka practised around 500 B.C.. Susruta
advised patients to eat the right food, to keep clean, to brush their
teeth with twigs, and to wash their eyes. He advocated enemas,
emetics, purgatives and sneezing powders. He kept his surgical
instruments in a clean box wrapped in flannel. Two millennia ago,
Harappa and Mohenjodaro had clean roads, water supply and a good
system of sewage disposal.

Now, in the 21st Century, we have more knowledge, sophistication and
expertise. Life expectancy has risen, even in India. With internet
facilities, doctors have access to the latest information with regard
to any disease. Medics armed with the finest skills spill out of
medical colleges like newly-hatched chicks to deliver health care.
But the public is disillusioned with our performance.

Something has gone very wrong. Specialisation is vital to medical
advancement but not when the motive behind it is aggressive
consumerism. Specialists should be available in recognised specialist
centres to which patients can be referred. But today's system does
not offer this type of service. It cleverly ensures that a patient
goes to several doctors before being told what's wrong. Even then he
is extremely fortunate if he gets to know the facts about his
illness. Hospitals with state-of-the-art facilities (a phrase that
makes my stomach turn) are springing up all over the place and they
are feted by fellow doctors and politicians: Cardiac Centres and
Kidney Hospitals; fertility centres; laparoscopy and lithotripsy
clinics; with a hospital administrator, marketing manager, public
relations officer, advertising panel and the hospital newsletter to
assist in caring for patients.

A few days ago, my friend (who compared doctors to politicians)
returned from Bangalore where he had to consult a cardiologist for
his two-year-old son. The child has a mild heart condition from birth
and needs a simple review to ensure that everything is normal. At the
hospital where he had met the cardiologist six months ago, he learnt
that she had shifted to another private centre 20 kilometres away.
After driving there he had to spend five hours standing at doorways
and jostling irate patients. In the end he saw the doctor for 10
minutes and had tests which took a quarter of an hour.

The brutal truth is that while we doctors pander to our egos and
greed, diseases like Tuberculosis, Leprosy, Anaemia, worm
infestation, Typhoid and Malaria — which can be prevented with simple
measures like hygiene, clean water and good nourishment — kill
millions every year. The medical speciality of Community and
Preventive Medicine which tackles these issues is, ironically, the
least attractive of specialities. First, because it is not lucrative;
and second, in medical colleges, the subject is taught with a
drabness that would send the most idealistic medic running in the
opposite direction.

If the plight of the common man when he falls sick is not the
doctor's responsibility, then what is? To fool patients into
believing that if they swallow pills, subject themselves to tests,
injections, operations or whatever, they will swing back to good
health?

I wonder if young medics busy imbibing knowledge and collecting
degrees will see some simple truths: There is a need for more doctors
in Community Medicine; and we badly want good General Practitioners.
When I was a girl, there was only one doctor to whom we went,
whatever the ailment. The smell of antiseptic and the fear of
injections prejudiced me against him then, but he was the most
important person in our village. He was trusted, and in return he did
his best for every patient. He was never hurried, harried or curt,
even with the girl who pretended stomach ache to avoid going to
school (having proclaimed that nothing was the matter, he offered
five empty penicillin vials to assuage hurt sentiments). His earnings
were modest. He saw us through the worst illnesses and, when it was
beyond him, advised expert opinion. This wonderful doctor of my
childhood was not even an MBBS but an LMP: A Licensed Medical
Practitioner.

People talk about the ignorance of the uneducated but the ignorance
of the moneyed class is amazing. They actually believe that five-star
hospitals where doctors oblige them with myriad tests are doing them
a service. The mysteries of the human body are not beyond our
comprehension. Before submitting to multiple tests, drugs or surgery,
one should ask the doctor about the reasons for doing them. Illness
is as much the patient's responsibility as the doctor's and it is
always better to understand what is happening within one's body. If
you have an illness and the doctor asks for half a dozen tests, find
out why. Especially when it's something as expensive as an MRI scan.
And talking of MRIs, every person with a backache seems to want one,
so well have the doctors "educated" them. Ninety per cent of back
ache sufferers need nothing more than careful guidelines about their
daily activities and regular exercises to strengthen the muscles
which support the back. An MRI is needed in rare cases where a
serious problem is suspected. It is not a routine test. Who will tell
them this?

We cant about the nobility of our calling, but Trust has become an
archaic word. It is still possible to pull ourselves back to where we
once enjoyed trust and goodwill, where science and humane values
coexist. The doctor of the future is the Community Doctor who is
interested in preventing an illness, and the General Practitioner who
is confident to treat your diabetes, or ulcer, a broken bone or
tonsils; who is caring, astute and wise enough to know when to refer
to a specialist and when not to.

Till then, we'll have to make do with state-of-the-art servicing of
our body parts.

Kavery Nambisan is a surgeon and novelist, whose book On Wings of
Butterflies will be released shortly. E-mail the writer at
vnambisan@yahoo.co.uk